Documentation on track with protocols

Plan ensures standard teaching and compliance

Although patient teaching was routinely done at Singing River Hospital in Pascagoula, MS, it was difficult to prove because it was not well-documented. Also, there was no way to determine if staff were following teaching standards that include assessment of learning needs and barriers before teaching and assessment of knowledge following the session.

To correct the problem, the patient and family education committee created teaching protocols for several diagnoses.

"Our main objective was compliance with the Joint Commission standards on patient education, including assessment and documentation," says Ann Dion, DNS, RN, director of education services at Singing River Hospital. (For more information on complying with Joint Commission standards, see Patient Education Management, November 1996, pp. 124-126; December 1996, pp. 135-136; February 1997, pp. 17-18.) Also, the committee wanted to ensure that everyone was teaching the same way and providing the same educational materials, so patients wouldn’t get conflicting information.

Documentation jumps

Quarterly chart audits in 1994-95 determined that patient education was being documented 58% of the time. After the protocols were implemented in 1996, documentation jumped to 92%.

"We find that staff are documenting more and following the standards," says Dion.

Following are details of how the protocols were created and implemented:

Select diagnoses to target.

Currently, there are 12 patient teaching protocols in place. They are diabetes, angina, hypertension, pacemaker, congestive heart failure, Coumadin therapy, open heart, cardiac cath, stroke, ostomy, chronic obstructive pulmonary disease, and asthma.

The first protocols targeted diagnoses that required major lifestyle changes, such as diabetes and hypertension. Then protocols were written for the hospital’s top DRGs. (See example of teaching protocol for diabetes, inserted in this issue.)

Assign writing task.

Singing River Hospital has a protocol committee that is part of the nursing standards system. The nurses on this committee write protocols for patient care, such as how to take care of patients with IVs. Because of their experience, they were asked to write the teaching protocols.

Although the committee was made up of nurses, the writing effort was interdisciplinary because the protocol was sent to each appropriate discipline for input on content. For example, the dietitian helped write the dietary portion of the diabetes teaching protocol, and a respiratory therapist worked on the protocol for chronic obstructive pulmonary disease.

Protocol sent out for approval

Once the protocol was finished, it was sent to the patient and family education committee for final approval.

"Sometimes the teaching protocols were sent back to the protocol committee for rewrites, but generally they were complete when submitted for approval. The patient teaching protocols were very similar to the other protocols the nurses were experienced at writing," says Dion.

Introduce protocol to staff.

Clinical educators taught staff how to implement and use the new patient teaching protocols. As soon as the first form was complete, they began conducting inservices on each unit. During the inservice, the educators went through the form and explained how to fill it out. As additional protocols were approved, the unit managers were asked to notify staff.

"Detailed guidelines were written that explain how to fill the forms in correctly, but we tried to get everyone to attend an inservice," says Dion.

Establish guidelines for implementation.

The admitting nurse initiates the protocol, which is kept in a patient education manual on each unit so they are easy to locate. If the patient is diagnosed with a disease after he or she is admitted to the hospital, the nurse that does the general assessment pulls the protocol and places it in the chart. If the complete protocol is not necessary, a generic, interdisciplinary patient education documentation form is used.

"The only time the disease-specific teaching protocol should be placed in the chart is after the patient has been assessed for his or her learning needs," says Dion.