Quote from superplum
I usually write something like "Provided with written and verbal pre-operative instruction. Patient and family verbalize understanding and will contact the nurse with questions as they arise." Am I missing something? Help!
It sounds like this is how your conversation with the patient went:
"Do you understand?"
"Are you ready to go home, and will your call the nurse if you have any questions?"
Really, is that verbalizing understanding?
You should be having the patient teach back the essential content (self-care skills, signs of a problem, what to do if those signs occur). Then your documentation should reflect your evaluation of the patient's understanding. Use a highlighter on key points in the printed materials that relate to your conversation. Document what the patient understood, not what you taught.
If you don't know how to do teach back, here is a great resource: http://www.nchealthliteracy.org/toolkit/tool5.pdf
If you want to learn more, see the website www.notimetoteach.com