Reader Questions

Clarify what’s expected in documentation criteria

Content should be consistent

Question: "How did you go about developing criteria for documenting patient education? What are your criteria? How do you assure that the disciplines providing the education provide consistent materials and content when teaching?"

Answer: Criteria for documenting patient education at the University of Washington Medical Center (UWMC) is based upon criterion created by the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations, says Cezanne Garcia, MPH, CHES, manager of patient and family education services at the health care facility in Seattle. Also helping to shape policy was the health care organization’s emphasis on measuring outcomes of teaching, not just providing evidence that teaching occurred.

The Joint Commission requires documentation of the assessment of learning needs, factors that impact learning and strategies used to optimize learning, outcome of teaching, and follow-up instruction, explains Garcia. To document the impact of teaching, or educational outcomes, a patient’s knowledge, comprehension, and skills are assessed.

Staff at UWMC have three options for documenting patient education. They include incorporating statements that describe the patient’s understanding or skill into progress or clinic notes; charting on critical paths with preprinted education interventions and outcomes; or using patient education records.

Procedures explaining the content requirements for documenting patient teaching for all three methods were compiled for staff. They include the following instructions:

Progress/clinic notes/dictation content.

Information in notes or dictation must include an assessment of the patient and family’s ability and readiness to learn. A brief description of the education process must also be documented that covers what was taught and why; how the teaching was provided; and the outcome of teaching such as being able to demonstrate how to change a bandage on a wound. Any educational follow-up required must be noted.

Critical path with education interventions and outcomes.

Those documenting on a critical path would specify the educational interventions used on preprinted sections, writing in the education provided if it was not listed. Tips for this form of documentation suggest that educational interventions include what was taught, why it was taught, and how it was taught. Tips for writing in education outcomes include giving examples of how the patient or family showed their knowledge or behavior change related to teaching and using action verbs, such as explains or demonstrates, to describe the patient’s knowledge, comprehension, or skill outcome based on the teaching.

• Patient education records.

The flowsheet, one topic, and two topic patient education records were created at UWMC to increase efficiency and documentation accuracy. They can be used as written or customized documents for specific topics or patient populations. ( See example of all three records, inserted in this issue .)

The flowsheet is designed for use when a large number of topics need to be covered or content provided in several teaching sessions or across the continuum of care. The one-topic record is tailored more for a single subject, and the two-topic record can be used for complementary topics taught between different disciplines, topics with differing outcomes, or topics taught within close proximity.

Like UWMC, Union Hospital in Elkton, MD, based its documentation criteria on Joint Commis-sion standards. Therefore, the health education committee included instruction for multidisciplinary teaching when creating its patient education policy by explaining the educational duties of each team member. However, documentation for all disciplines is the same.

"Basically, every instance of patient education documentation must contain three elements," says Jean M. Webb, RN, patient education coordinator at Union Hospital. These include who was taught, what was taught, and whether the person(s) taught understood the material. Documentation is done in the nurse’s notes, department specific progress notes, standard educational guidelines, disease specific checklists, and physician progress notes.

Keeping education on track

While patient education managers must make sure documentation is complete, at the same time they must ensure that it is consistent. Several checks and balances have been instituted at UWMC to ensure that all disciplines provide the same information across the continuum of care, says Garcia. For example, criteria for approving the purchase or development of patient education materials were established and an inventory of materials is available via the medical center’s in-house materials. The development of teaching plans for strategic patient groups also is encouraged.

At Union Hospital a file cabinet containing standard educational guidelines is kept on each unit. "The guidelines are listed in alphabetical order and each has its own file. Within that file is the "hard" copy of the standard educational guideline along with any videos, pamphlets, or other printed material that may be related to that particular topic," explains Webb.

The medical staff have approved the guidelines and all related information; therefore, only materials contained in the files can be used for teaching. ( See sample of a standard educational guideline for angina, inserted in this issue.) "Patient education material may also be obtained from preapproved Internet sites in specific cases," adds Webb.

Sources

For more information on creating criteria for documentation of patient education, contact:

Cezanne Garcia, MPH, CHES, Manager, Patient and Family Education Services, University of Washington Medical Center, 1959 Pacific St. N.E., Box 354618, Seattle, WA 98195. Telephone: (206) 598-8424. Fax: (206) 598-7821. E-mail: ccgarcia@u.washington.edu.

Jean M. Webb, RN, Patient Education Coordinator, Union Hospital. 106 Bow St., Elkton, MD 21921. Telephone: (410) 398-4000 ext. 1541. Fax: (410)
392-9486. E-mail: jwebb@uhcc.com.