Reader Questions: Audits become best documentation motivator

Effective form just the first step

Question: "What have you done to improve documentation of patient education? What have been your most successful methods for improvement? How do you monitor compliance numbers and what do you do if those numbers begin to slip?"

Answer: It is not enough to create a form for documenting patient and family education, documentation must remain at the forefront of staff education for compliance to be consistent. "I have tried many approaches to improving documentation. What I have settled on is a chart audit approach conducted by a couple RN’s," says Kris Becker, RN, MHA, director of orthopedic services at Sacred Heart Medical Center in Spokane, WA.

As these two nurses track monthly compliance with documentation and education standards on a chart audit tool, they simultaneously fill out a feedback sheet for staff members who provided the documentation. The feedback tool follows the chart audit and has preprinted information and reminders. (See example of information included in feedback tool in "Feedback tool improves staff documentation.")

Becker tracks the specific area of deficiency for each individual staff member and uses the data to identify trends. She also uses the data as part of staff’s annual performance appraisal. "It is not an option to not follow the documentation policy," she explains. When a staff member receives a feedback sheet, he or she is required to sign the form and return it to her within two weeks.

"I occasionally have staff do unit chart audits. However, I do not use these audits for data collection, only for education purposes," says Becker.

WellSpan Health in York, PA, also uses chart audits to track documentation and completes audits on a semiannual basis. Auditors verify if a documentation form was placed in the chart, if barriers were addressed, if all appropriate disciplines used the form, and what was documented, explains Nancy Miller, RN, MBA, patient and family education coordinator at WellSpan. Last winter, audits revealed that 85% of the charts had patient education forms with some documentation, but only 54% had barriers addressed, and nursing was the only consistent group to document.

To bring the numbers up, several areas have the nurses bring the teaching record to multidisciplinary rounds along with the patient’s plan of care to be sure appropriate education is being provided and documented. When a specific nursing unit identifies that there is not consistent documentation, they develop a plan to address the problem.

For example, the maternity area decided that each nurse would have three charts to review for one week, then rotate to three others on an ongoing basis to track the documentation compliance of a colleague. The nurse was responsible for telling the colleague reviewed if there was a problem and also report it to the manager. "The nurses felt this would also help them to identify what they were forgetting. After two months, they found that documentation had improved significantly," says Miller.

The multidisciplinary committee for patient and family education also is proving to be helpful with documentation adherence. Group members stress the importance of documentation to all who provide patient teaching, says Miller. Each discipline has annual education days where they review patient education and its documentation. In addition, every discipline is encouraged to remind their colleagues to document when they see them providing education. Patient education was added to the health care institution’s annual competency education as well.

"With our focus on a known location and re-emphasis on patient education our numbers have improved," says Miller. The last audit revealed that 95% of the charts had education forms with documentation, 87% had the barriers to education addressed, and 92% had all appropriate disciplines documenting.

A commitment to remain in a constant state of readiness for a Joint Commission on Accreditation of Healthcare Organizations survey helped boost compliance with documentation of patient education at Shands at the University of Florida in Gainesville. To remain ready, a Joint Commission clinical group was formed that is chaired by the director of nursing and director of operations and has representatives from all the clinical disciplines.

Members of this committee are given chapter assignments from the Joint Commission Standards and are responsible for ensuring that the health care facility is meeting the standards within those chapters. One group looks at patient education, which includes documentation, explains Kathy Gamble, ARNP, MN, CPON, OCN, coordinated care manager of the department of nursing and patient services at Shands and co-chair of the interdisciplinary patient and family education committee.

To help monitor documentation, the medical records department conducts monthly closed chart audits. When the audits first began, the numbers revealed a need for a lot of work. Therefore, a one-time meeting was held to develop an action plan, says Gamble. The group that met included the members of the patient education committee, the Joint Commission clinical group, the closed-chart review group, licensure and accreditation, and nursing documentation.

The patient education committee implemented the plan, which included making the documentation requirements for education records a hospital policy. To make documentation of patient education less time-consuming, the record is referred to as an index to patient education. Disciplines that have detailed education notes on another part of the chart are asked to make a note on the record so they don’t have to double-document, so the information can be found easier, says Gamble.

"It has helped for staff to know that documentation is something we are watching. It has improved our compliance," says Gamble. 

For more information about increasing staff compliance in the documentation of patient education, contact:

  • Kris Becker, RN, MHA, Director of Orthopedic Services, Sacred Heart Medical Center, W. 101 Eighth Ave., Spokane, WA 99220. Telephone: (509) 474-7126. E-mail:
  • Kathy Gamble, ARNP, MN, CPON, OCN, Coordinated Care Manager, Department of Nursing & Patient Services, Shands at the University of Florida, Box 100335, Gainesville, FL 32610. Telephone: (352) 265-0392. E-mail:
  • Nancy Miller, RN, MBA, Patient and Family Education Coordinator, WellSpan Health, WellSpan Human Resources Center, Suite 101, 1135 S. Edgar St., York, PA 17403. Telephone: (717) 851-5859. E-mail: