Narrative Teaching Documentation

[superplum]

Folks,

I do a lot of surgery teaching (I work in an out patient breast cancer clinic) and am wondering if I can improve my narrative charting on the teaching I do with the patients? 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!

Thanks Party People!

Superplum

[T-Bird78]

That sounds pretty generic and vague but covers all the bases. If it's routine (for your facility) care, can you have a checklist printed up with all the info sheets you give the patient and check it off, sign and date, maybe even have the patient or pt's support person initial it? When my hubby had outpatient surgery I had to sign the after-care instructions and the nurse signed and gave me a copy and the original went in the chart. Could that work?

[superplum]

Lol, yep it's pretty vague, so any clarification will be an improvement! I'll talk to my manager and see if we can put a form like that through to Forms Committee (everything in the chart has to go through those guys...yuck!), until then, any suggestions for additions/changes to my narrative charting would be great. We do have forms for outpatient procedures that pts can sign, so maybe I can riff off one of those - most of the teaching I do is for pts who will have inpatient procedures though.

[franlondon]

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!

Superplum

It sounds like this is how your conversation with the patient went:

"Do you understand?"

"Yes."

"Are you ready to go home, and will your call the nurse if you have any questions?"

"Yes."

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 http://www.notimetoteach.com

[superplum]

Franlondon,

You're right it's not really verbalizing understanding!

These are great resources, I didn't know about teach back! I'll spend more time checking them out!

[Anna Flaxis, BSN, RN]

I usually do a narrative similar to yours, but we also have supplemetal teaching sheets that have a checkbox for each category of information, and a check box for any return demonstration by the patient or their caregiver. In my ED, we had patients sign a copy of the discharge instructions, stating that I had gone over the info with them and that all of their questions had been answered.