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Streamline documentation for outpatient education
Examine the process as well as the form
Documentation is becoming a routine part of patient education in inpatient settings. However, many health care providers have not yet formed this good habit in outpatient areas.
Documentation of teaching in outpatient settings is important for all the same reasons that support it at a patient’s bedside within the hospital, says Marjorie Schirado, RN, patient education coordinator at Medcenter One Health Systems in Bismarck, ND.
Proper documentation establishes a paper trail showing that education took place. This is important for the legal department should litigation occur.
Schirado says the risk management department has determined that the most common patient complaint is that the patient was not told something important or that the patient did not have enough information. With proper documentation, it is easy to trace the name of the educator, what was discussed, and what literature was provided, she says.
Documentation of patient education is required by the Joint Commission on Accreditation of Healthcare Organizations, and must be completed if an institution is to become accredited.
Most importantly, documentation of patient education allows providers to build on the education given by others on the health care team. "If we can see what teaching has been provided, where that person was in the learning process, and build on that, then he or she receives more continuity of education," says Schirado.
At Roswell Park Cancer Institute in Buffalo, NY, treatment takes place in many settings, which makes it important to trace education across the continuum of care, says Megan D. Battaglia, patient education facilitator.
It is not as if all the members of the team treating the patient are in the room at the same time. Therefore, it is important to document a patient’s educational needs and barriers to learning, says Battaglia.
While reasons for documenting remain similar in both inpatient and outpatient settings, many issues make documentation of education different in each setting. For example, an outpatient clinic sees more patients, says Schirado. Also, educators don’t have the option of coming back in an hour or two to finish a conversation or evaluate a patient’s learning, as they do when a patient is in the hospital.
On the inpatient side, education will include diagnosis, procedure, possible complications, medications, equipment, supplies, and diet. However, education in an outpatient setting focuses on one or two areas that are new for the patient, such as a change in medication or diet, says Schirado. Due to these subtle differences, patient education documentation forms for outpatient areas work best if geared to the outpatient setting, she says.
Tailor forms to the setting
Medcenter One Health Systems began as a single hospital and then acquired clinics. While some of the clinics are close to the hospital, others are up to 100 miles away. When determining how to document education in these clinics, Schirado considered using the inpatient form, but she knew that only one or two areas would be marked during a visit. That would result in a lot of wasted paper, she says. Also, it would be difficult to follow the continuity of education if a separate sheet was used to document teaching at each visit.Therefore, Schirado implemented a multi-visit form that provides space for documentation of education at four clinic visits. (See Clinic Patient Education Record.)
Each section has a column to document which topic is being taught (such as medication) as well as columns to note barriers to learning, the literature provided, verification of learning, and referrals made for further education, such as a class on diabetes.
When designing documentation forms for outpatient areas at Kishwaukee Hospital in DeKalb, IL, patient education coordinator Andrea Diedrich, RN, MS, and her colleagues patterned the forms after the general patient education flow sheet used in the hospital. The standards for documenting patient education are the same no matter the setting, she says.
However, the forms for the physical therapy area, cardiac rehab, pain clinic, and sleep lab are streamlined.
"Our forms are shorter, more specific to the needs of each area, and designed for the shorter, quicker visits that are typical in outpatient areas," says Diedrich.
Education noted in outpatient assessment
During multidisciplinary rounds at Roswell Park Cancer Institute, the educational needs and barriers of each patient in the hospital are discussed and documented. However, in the outpatient setting, the patient is not seen by a team of health care workers from social work, nutrition, physical therapy, and occupational therapy along with physicians and nurses at the same time.
To ensure that all team members know what education takes place outside the hospital, Battaglia incorporated all the aspects of the two-page inpatient documentation form into the nursing assessment in the outpatient area. Education is assessed along with blood pressure, medications, and a patient’s medical history.
"We wanted to make it a part of a form that everyone uses, sees, and reads," explains Battaglia. Everyone who sees the patient will look at the assessment and see the education. They don’t have to search for it on a separate form, she says.
The short section inserted into the nursing assessment includes barriers to learning, learning needs, the patient to whom education was provided, the method of teaching, the patient’s response, and the required follow-up.
To determine which method of documentation to use in outpatient areas, Battaglia went to staff to discuss the issue. She was told it would be difficult for staff to document consistently if a new form was introduced into the medical record. "You can’t expect cooperation unless you ask how to make the documentation process easier," she says.
By examining how patients were seen in the outpatient setting, Battaglia was able to devise a way to make documentation of education more natural.
"It is part of the process, and it has increased our documentation tremendously because it is part of the natural order. They don’t have to seek out the form, and we don’t have to prompt them to document; it just happens automatically," says Battaglia.
At Kishwaukee Hospital, Diedrich found that, if forms are similar in all areas, it is easier for staff to read and understand them. The outpatient forms in this hospital are therefore patterned after the inpatient forms.
When designing the documentation form for the clinics at Medcenter One Health Systems, it was important to keep real time in mind, says Schirado.
If a provider sees 40 patients in one day, the result could be an overwhelming amount of documentation, because every patient receives some education. In addition, there is only a short amount of time to assess a patient’s learning needs, plan an education strategy, implement it, and evaluate that education. It takes about 15 seconds to document education on the outpatient form, says Schirado.
While it would be nice to have all education documented, Schirado encourages staff to at least document anything new that is taught. For example, if a patient has a new diagnosis, is undergoing a new procedure, or is receiving a prescription for a new medication, it is important that the staff educate the patient and provide written materials to reinforce the teaching.
Compliance with documentation requirements is higher if it is monitored on a regular basis, says Schirado. Providing a way to test staff competency in this area also helps, she adds.
This year she put together a two-page information sheet on patient education along with a ten-question posttest. She distributed the information sheet and test to everyone who teaches patients, including disciplines such as respiratory therapy. Schirado asked staff members to return the posttest to her along with a copy of documentation of the education they provided to an actual patient.
"This helps me to get a look at all the different ways that people actually do document so that I can determine what education to provide staff," says Schirado.
For more information about documenting patient education in outpatient settings, contact: