Successful forms for outpatient documentation

Tailor to short encounters with simplicity

Question: How are you documenting patient and family teaching in the outpatient setting in general and specifically in an ambulatory care center? I have a good inpatient documentation form, but outpatient instruction is often short term.

Answer: There is not much time for instruction in an outpatient setting or to reinforce the information, agrees B.J. Hansen, BSN, patient education coordinator at Grant/Riverside Methodist Hospitals in Columbus, OH. Therefore, the patient’s ability to recall what was taught is often poor, so documentation is vital for legal reasons in an outpatient setting.

"Staff need to document what was taught, what resource numbers for questions and problems were provided, and what written materials the patient received to reinforce the teaching," says Hansen.

Communication is another vital reason to document patient education. In an outpatient setting, with many care providers, documentation helps staff build on previous lessons, says Hansen.

A third reason to document outpatient education is that it is part of standards on patient and family education from the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations.

The outpatient setting has unique requirements, and inpatient forms need be altered to fit, says Betsy McCune, RNC, MS, clinical pathway coordinator at Providence Alaska Medical Center in Anchorage. "Outpatient documentation can be briefer and cover fewer topics because the presenting complaint is the focus of the education," she explains.

In several areas, such as the emergency department and OB triage, staff have one opportunity for teaching, and readiness to learn is minimal. In these clinical areas, it is vital to minimize what is taught but to teach it well, says McCune. Therefore, the medical center recently initiated an OB Triage Patient Family Education record. It has a learning assessment check-box approach to document how barriers to learning were overcome, and the key learning objectives that every patient must complete prior to discharge. (See example of OB Triage form, inserted in this issue.)

It is sometimes possible to take bits and pieces from the inpatient teaching documentation form when creating the outpatient form. "We use the same learning assessment because it is excellent and easily completed," says McCune. However, the approach to overcoming learning barriers section is designed to be completed quickly, with staff noting how barriers were overcome and if follow-up is needed.

The OB Triage education record has a place for the patient or family to sign indicating that they have reviewed and understand the instructions given. The signature is necessary from a legal standpoint.

In the ambulatory care center at Mid- Florida Medical Services in Winter Haven, the brief episodes of teaching in the ambulatory care center are simply written in the nurse’s notes. However, all discharge instructions are preprinted on forms that have a carbon copy for the patient. The nurse reviews the information with the patient, and the patient and nurse sign the form, says Laurel Spooner, RN, BSN, education coordinator for Mid-Florida Medical Services.

This method of documenting the teaching works well in the ambulatory care center but not in other outpatient settings. For example, the radiology department uses a preprinted patient education flow sheet that prompts the health care professional to give the patient information on the procedure and what the patient is supposed to do, explains Spooner. The sheets are generic, so a sticker is placed on each one to identify the procedure. For example, if the patient is having an upper GI, then that sticker would be placed on the sheet.

Use of education tool

Fitting the form to the setting is important, agreesGary Lewke, RPh, manager of the Providence Alaska Medical Center Infusion Center in Anchorage. Therefore, a special education tool for the center was created that focuses on the procedures done at the center including chemotherapy, blood transfusions, and IV antibiotics.

Simplicity is key in the outpatient setting, says Kelly Koch, BSN, clinical supervisor for the medicine clinic at Fairview-University Medical Center in Minneapolis. To ensure that brief teaching episodes were documented in the ambulatory care setting, a one-page flow sheet was developed.

"It’s in the front of all our charts, so anyone can pick up that chart, look at the sheet, and see what sort of teaching has occurred," says Koch.

Codes are used to make documentation quick. For example, G indicates that information was given, and V indicates the patient verbalizes understanding. (See example of ambulatory care teaching flow sheet in materials packet insert.)

At The Ohio State University Medical Center in Columbus, inpatient documentation forms cross over to the outpatient setting because the teaching-learning flow sheets used for documentation are disease and procedure specific.

"People in outpatient ignore the parts that aren’t applicable to their setting by either writing NA or crossing the information out," says Sandy Cornett, RN, PhD, program manager of consumer health education at the medical center.