Forms guide individualized discharge instruction

Categories prompt correct response in all areas

Question: "How do you individualize discharge instructions for each patient and maintain a record of the individualized written instructions for the patient record in compliance with Joint Commission standards?"

Answer: Patient Education Management interviewed several patient education coordinators to compare the various systems in place. Following is a brief summary of the information garnered from each institution:

• Children’s Healthcare of Atlanta.

Standardized discharge forms are used most often at Children’s Healthcare of Atlanta, with the forms individualized to each patient by writing the information in each table. For example, the instructions for a teenager going home on a clear liquid diet following surgery are different from a child with asthma going home on a regular diet.

The nurse writes in the discharge instructions per physician order. The family and nurse sign the form; one copy goes to the family, while the second is placed in the medical record.

In addition to the general discharge form, the health care system has created discharge teaching forms specific to patient populations, such as oncology. The template has information that is specific to that patient group, says Kathy Ordelt, RN, Patient & Family Education Coordinator at Children’s Healthcare of Atlanta.

For example, the form might have information that instructs patients to call their physician if their temperature reaches 101 degrees. These forms also have boxes for individualized information. "The preprinted forms are for staff convenience to make it easier to capture all the information so it doesn’t have to be written every single time," explains Ordelt.

No matter where the patient enters the health care system including the emergency department, primary care setting, or inpatient setting, there is a discharge record that can be individualized. "They are formatted in a similar fashion, but they all contain different content that makes it appropriate for that clinical practice setting," says Ordelt.

• Michael Reese Hospital and Medical Center.

An interdisciplinary discharge education form was created at Michael Reese Hospital and Medical Center in Chicago so more than one department can use it. It is divided into sections with clear headings so it is easy for patients to find the information they want. Headings include diet, drugs, dressings, home health, and contact information for the nursing unit, the case manager, and physician.

A follow-up appointment is written on the sheet, if known, or instructions to call for an appointment within a given time are written. "This form is in triplicate, and one goes to the patient, one on the medical record, and one to the attending MD as needed," explains Michele Knoll Puzas, RNC, MHPE, pediatric nurse specialist at Michael Reese.

Post-discharge phone calls are randomly made to assess the effectiveness of discharge teaching. In pediatrics, a problem with discharge education is seldom uncovered, but parents frequently have new questions that staff can answer.

• St. Francis Hospital and Health Center.

The discharge instruction sheet at St. Francis Hospital and Health Center in Blue Island, IL, is a three-part form so there is a copy for the patient, the physician, and the chart. It is meant to be an education summary, says Allison M. Reid, MS, RNC, an educator at the health care facility.

In addition to categories for medications, bathing, diet, wound and incision care, and follow-up care, there is a place for post-hospitalization instructions, such as a lab test the patient needs to have done in a week. The form also has a section for rehabilitation instructions, equipment, and community services.

• University of Missouri Hospitals & Clinics.

Patient Teaching Records that reference use of approved patient education materials were developed at the University of Missouri Hospitals & Clinics in Columbia and are written with outcome statements for the patient to meet. If the outcome is met, staff document by dating and initialing the "outcome met" column. "If outcomes are individualized or additional content is taught, it should be documented in detail on the patient teaching record," says Ceresa Ward, MS, RN, manager of Health Improvement Services at the medical center. Space is available for additional comments to note patient or family questions, response, or other details of teaching.

The Discharge Orders/Instructions forms used for all patients leaving the hospital complement the Patient Teaching Records with brief general information that gives choices the provider can check or use one to two lines to write in specifics. The topics covered include activity, bathing, wound care, driving, diet, medications, signs of infection, follow-up appointments, and dispensation arrangements such as the number of the home health agency.

The form is signed by the patient or caregiver who receives a copy with a second copy placed in the chart.

For more information on individualized discharge instructions, contact:

Kathy Ordelt, RN, Patient & Family Education Coordinator, Children’s Healthcare of Atlanta, 1001 Johnson Ferry Road N.E., Atlanta, GA 30342. Telephone: (404) 929-8641. Fax: (404) 929-8690. E-mail: kathy.ordelt@choa.org.

Michele Knoll Puzas, RNC, MHPE, Pediatric Nurse Specialist, Michael Reese Hospital & Medical Center, 6705 W. 64th St., Chicago, IL 60638. Telephone: (312) 791-2932. Fax: (312) 791-2651.

Allison M. Reid, MS, Educator, St. Francis Hospital & Health Center, 12935 S. Gregory Ave., Blue Island, IL 60406. Telephone: (708) 597-2000, ext. 5854. Fax: (708) 597-1381. E-mail: areid@ssmhcs.com.

Ceresa Ward, MS, RN, Manager, Health Improvement Services, University of Missouri Hospitals & Clinics, UP Office Building, One Hospital Drive, Columbia, MO 65211. Telephone: (573) 882-7126. E-mail: wardc@ health.missouri.edu.