Patient Education - Why Don't You Document?

[Q.]

I know this is an on-going issue not just in my facility, but in others across the US. I know it's an issue because Patient Education Coordinators and Specialists across the country all discuss this very, very important issue and it becomes our problem in a very big way.

I'd like to know why staff nurses find it difficult to document patient education, whether it's a paper chart form or electronic charting?

Nearly every time an audit is done, 80% of patient education is not documented. Many of these undocumented forms get inspected by JCAHO and CMS, and many others are publically reportable - in other words, our compliance scores are posted publically for people to view and then compare against other hospitals.

We, like other hospitals, scored horribly, and showed that only 20% of our patients recieved discharge teaching on cardiac disease. I know that most likely, education was given but it just wasn't documented. And as we all know, if it's not documented, it's not done.

The last time I staffed the floor was 4 years ago, so I'm not THAT far out of touch with patient care. I worked in an LDRP, and I did my patient teaching and simply documented such on our teaching sheet.

I've seen teaching sheets not filled out at all, or partially filled out, etc. What would make documentation for you easier?

[suzanne4, RN]

The last two facilities that I have worked at require documentation every shift. At the facility now, there is a chart audit done by the shift following to make sure that everything was done, so it gets done..........:wink2:

I prefer the form where the care plan as well as education is part of the same form, essentially a multidisciplinary form. Makes it easier on everyone and is much more complete.

[nursemaa]

I wonder the same thing. We've even simplified the documentation- most of it involves just checking a box and initialing, but it doesn't get done for some reason. I think many times nurses actually do the teaching, but don't document it, I just wish I could figure out why.

[fergus51]

We have education sheets that MUST BE filled out prior to discharge. Since that policy went into effect, nurses have become much better at documenting teaching because they don't want the nurse who happens to discharge the patient to be forced to complete it all. That said, some of them are just stupid because they aren't specific enough to our unit. I can't tell you how many times I have had to put "N/A" on half the sheet (No, the baby can't verbalize the supports it has in the home).

[KatieBell]

Oh but I Do!!!!

I always document it. I'm at a facility using paper and I find it a bit tedious to write it all out- especially if I start Lovenox and give education....

I much prefer being at a place where I can electrontically choose from the Patient education template.

I think it is just that nurses forget- especially in the ED the patient is in and out so fast sometimes...

[Mulan]

The shift assessment form has a section for patient education, yes or no, and if yes document what it was. This is computer charting.

[Mulan]

Do anyone else have tan boxes next to the warning area under their name? What are the boxes for?

[truern]

We have to document pt ed each shift on the flow sheet. Just check what was taught, how it was taught, to whom, that they verbalized understanding (or whatever) and if further instruction is needed. Check, check, check, etc etc etc

[perfectbluebuildings, BSN, RN]

We have a computerized form to fill in who was taught, what was taught and the outcome. It's supposed to be documented every shift. Sometimes I think it is hard to remember just because often, it is talking and answering patient's questions, and not a specific task like assessment or medications, and I don't always remember exactly like I should what I talked with them about throughout the day. Of course, admitting and discharging is different and much more specific, but the daily stuff can be hard to remember. I suppose I should make it a priority to write down, along with all the numbers and such, as I go from room to room, on my "brain" paper. Interesting question!!

[Q.]

Sometimes I think it is hard to remember just because often, it is talking and answering patient's questions, and not a specific task like assessment or medications...

That's a great point and I'm guessing you hit the nail on the head a little bit.

I wonder how we can change the mindset of nurses to think of patient education as a skill? You know, assessing the learner for readiness, picking an appropriate learning method based upon the previous assessment, etc? You know?

[purplemania, BSN, RN]

There is so much documentation to be done that, in my opinion, nurses prioritze and education is on the bottom of their list. What many do not realize is they are not giving themselves credit for what they do. Education is so much more than a formal class. We educate by everything we do and say to the patient. Perhaps if we could find a way to demonstrate to the nurses how this documentation impacts THEM personally we might get more compliance.

[purplemania, BSN, RN]

There is so much documentation to be done that, in my opinion, nurses prioritze and education is on the bottom of their list. What many do not realize is they are not giving themselves credit for what they do. Education is so much more than a formal class. We educate by everything we do and say to the patient. Perhaps if we could find a way to demonstrate to the nurses how this documentation impacts THEM personally we might get more compliance.