Create a paper trail to improve teaching, communication, and documentation

Methods should be tailored to needs of institution and patient population

In an effort to spur documentation, standardize teaching, and ensure patients will be ready for a safe discharge, many institutions utilize checklists, guidelines, and teaching plans. However, the implementation of these tools doesn’t necessarily guarantee the desired result will be achieved. It is important to implement such tools with care and be willing to replace or eliminate them completely if they are not working.

The Children’s Hospital of Philadelphia had individualized teaching plans in place for almost every diagnosis and procedure with matching handouts for parents. The purpose of the plans was to prompt both teaching and documentation. These were tools to be used throughout the patients’ stay to help nurses plan their day and communicate which teaching had been completed. However, instead of using the tool day by day, they usually drew an arrow from the top of the page to the bottom of the page on the final day and signed the sheet.

"It was looked at as another piece of something to do," says Linda S. Kocent, RN, MSN, coordinator of patient-family education at The Children’s Hospital of Philadelphia. Children’s Hospital now is phasing out the teaching plans as they come up for their three-year review if there is another tool such as the nursing standard, nursing procedure, or a teaching sheet that has the same information staff need to teach the family.

Also, it is crucial to show the assessment, the education plan, and work being done in one place. Therefore, rather than have separate forms that never really show the plan, a teaching record called the Interdisciplinary Patient-Family Education Flowsheet was implemented for documentation. The form has sections for documenting the assessment, the learners, their learning style, the method of teaching, and the outcome of the teaching session. Also, it is not for nurses only.

"The teaching plans could have been useful, but they weren’t used correctly and the information was redundant — so why give nurses one more piece of paper to fill out?" asks Kocent.

Patient education managers need to make sure they are not duplicating documentation for staff, agrees Mary Szczepanik, MS, BSN, RN, manager of cancer education, support, and outreach at OhioHealth Cancer Services in Columbus. Also, when creating a tool its purpose needs to be very clear.

Teaching plans can be very valuable to your medical team, depending on your practice, says Cezanne Garcia, MPH, CHES, manager of patient and family education services at the University of Washington Medical Center in Seattle. "In our case, we tend to have an extreme cross mix of types of patient groups — especially in our inpatient care areas where the patients from three to four services converge on one floor. The staff there not only need to know a wide range of clinical care practices and related expertise, but also what the teaching [needs are] for patients and family to successfully go home," says Garcia.

The patient education department helps the teams creating the teaching plans hone in on the essential "need-to-know" information for a safe discharge. The plans include a short list of teaching tools that can be used to reinforce one-on-one teaching such as videos. Documentation of education is part of the plan so the medical team can easily see what has been covered and what needs to be reinforced. According to Garcia, patients who sit on the medical center’s advisory councils tell them they prefer to hear complex information three or four times.

Plans never nullify good teaching

Some patient education managers are concerned that teaching plans give staff permission to skip the initial assessment and go right to the need-to-know information. However, Garcia says patient’s concerns always must be addressed in the education process. Patients do not always understand the complexities of a safe discharge; therefore, it is important to partner with patients and family members to help them understand the importance of using a piece of technical equipment correctly or how to care for a wound.

Without the assessment — teaching plan or not — barriers to learning will not be addressed, says Nancy Goldstein, MPH, patient education program manager at Fairview-University Medical Center in Minneapolis.

At the medical center’s Patient Learning Center, about 50 guidelines have been created for educators to use to help patients achieve success in learning a technique for safe discharge, such as administering IV antibiotics. These guidelines have accompanying flowsheets for documentation that are sent back to patient units so bedside nurses will know which patients have been taught at the Learning Center and what information needs to be reinforced.

If the patient is not ready to learn, the teaching session is rescheduled for a later date. For example, if the patient is anxious, the educator will address the problem and postpone the education.

"If a patient can’t get beyond a certain point, we make an assessment (Is it a bad day? Do we need to teach a family member? Do they need home care?), and then implement the plan," says Goldstein.

One of the reasons the guidelines were implemented was consistency. A patient coming to the Learning Center on Monday should find no difference in the content or steps in education if he or she returns on Tuesday and is taught by another educator. The guidelines are given to the patient care areas so staff know how the Learning Center is teaching and can reinforce it, says Goldstein.

To be useful, teaching tools must focus on the outcome of the education, says Szczepanik. Often checklists are created as a tool for documentation of patient education, and while they may seem like a series of topics that need to be checked off, good teaching principles still are required. That includes completing a patient learning assessment before the topics on the checklist are tackled, she adds.

The initial assessment includes readiness to learn, preferred learning style, and a determination of what the patient knows and would like to know. The teaching is followed by an assessment to determine what the patient learned, or the outcome of the education, she explains.

There are many benefits to using a checklist, says Szczepanik. They decrease the amount of time the nurse and others spend writing, and provide a way for staff to communicate what the patient has learned and what still needs to be taught. Checklists can provide a paper trail for documentation and, because it is a quick read, it is more likely to be reviewed by staff. Reading narrative notes about what the patient was taught is not practical, explains Szczepanik.

"I teach staff nurses that you must document what you taught and you must be able to recreate by looking through the documentation in a medical record not only what was taught but how well you think the patient learned it. The last step I am going to look for (and probably any attorney would look for), if you didn’t have time to teach everything or you don’t think the patient learned it well enough to be independent at home, is an indication that some kind of home health referral was done to finish the teaching," says Szczepanik.

A teaching checklist is just a tool in the process of patient education. While a checklist is a good reminder of the topics that patients need to learn, it shouldn’t be the purpose of the form. Checklists are not meant to prompt the teaching; they are meant to prompt the documentation, she explains.


For more information about creating tools to standardize teaching, trigger documentation, or help ensure a safe discharge, contact:

Cezanne Garcia, MPH, CHES, Manager, Patient & Family Education Services, University of Washington Medical Center, 1959 N.E. Pacific St., Box 356052, Seattle, WA 98195-6052. Telephone: (206) 598-8424. E-mail:

Nancy Goldstein, MPH, Patient Education Program Manager, Fairview-University Medical Center, 420 Delaware St. S.E., Minneapolis, MN 55455. Telephone: (612) 273-6356. E-mail:

Linda S. Kocent, RN, MSN, Coordinator of Patient-Family Education, The Children’s Hospital of Philadelphia, 34th Street and Civic Center Blvd., Philadelphia, PA 19104. Telephone: (215) 590-3661. E-mail:

Mary Szczepanik, MS, BSN, RN, Manager, Cancer Education, Support, and Outreach, OhioHealth Cancer Services, 3535 Olentangy River Road, Columbus, OH 43214. Telephone: (614) 566-3280. E-mail: