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?

[sbic56, BSN, RN]

http://www.logicare.com/products_patienteducation.htm

Systems like Logicare help. This is used in a place where I work. It generates printouts for every diagnosis imaginable. It's quick and provides documentation of education given to the patient. Nurse and patient signature is entered, so it helps to address the liability issue. I think it's smart technology.

[IMustBeCrazy]

I can appreciate that, but at the same time the lack of documentation of patient education increases our liability.

How does it look if a heart disease patient was seen in our facility and discharged without any evidence of teaching how to take care of himself, and then subsequently dies?

How does it look when a Medicare patient is discharged and then readmitted within 30 days with the same diagnosis; and now as a result the hospital is not reimbursed for that care because it's obvious we didn't do our job if the patient is readmitted again for the same thing?

Patient education is often shuffled down the list as least priority, but it really is as much of a priority as any treatments given.

If patient education has a history at your institution of not being documented, then this is a SYSTEMS problem, not a nursing problem. If better SYSTEMS including double checks etc. were in place (whether they be electronic or paper) then this would not occur. It's just always easier to point fingers at the nursing staff rather than address the core problem.

[SmilingBluEyes]

If patient education has a history at your institution of not being documented, then this is a SYSTEMS problem, not a nursing problem. If better SYSTEMS including double checks etc. were in place (whether they be electronic or paper) then this would not occur. It's just always easier to point fingers at the nursing staff rather than address the core problem.

EXCELLENT POINT. That was what I was eluding to earlier, but you said it better. It is quite interesting how we immediately blame "nursing', but don't offer much in the way of SOLUTIONS to making our jobs easier when things like documentation are incomplete.

It would seem to me, a nurse educator would easily understand this, having "worked the floor before". One suggestion, perhaps, would be to assemble a process improvement team/project, which would be multidisciplinary (nursing from various units/floors, management personnel, Nursing Education, and IS--- for instance) and examine what is REALLY going on and brainstorm some viable and workable solutions. I think that would be an excellent start.

[Indy, LPN, LVN]

We have these complicated education sheets to fill out for our patients on various subjects and it crosses my eyes to look at them. The one in the admission form, well that is all common sense and takes 30 seconds to tell the patient the content, so I don't mind documenting that at all.

On night shift I'll ask if the patient understands their upcoming procedure or what they expect when they go home, most of the time they got an earful from day shift so I let 'em sleep. I'll intervene and teach specifically if I hear dangerous things like "can I keep the arm sling on for two weeks straight after I go home?" (post pacemaker placement) or if they really don't understand their meds, or think that by "bed rest" I meant get up and walk to the smoking area, etc.

Now, will I document that? Depends on whether or not their need for immediate, on the spot teaching took up so much time that I can barely finish my other tasks. If you ask me, teaching's ingrained in the communication we do, the documentation is forbidding and redundant. Example: If it asked whether I taught, ok fine. BUT it wants to know WHO I taught, what teaching method, and what level of learning occurred.

?! If it's the dangers of smoking and drinking, they're gonna say "ok" to get me to shut up. I don't have any way of knowing, for some subjects, whether they will listen or not. Not only that, the little codes for these pieces of information, and the date and my initials, go in a little box that's about a half inch square. Whoever made that form is a sadist.

I agree with the necessity of education, but I don't agree that patient education alone is going to prevent readmissions. People think their bodies are like automobiles: they break 'em and we fix 'em. Until people think differently and take responsibility for their lifestyles, they're just gonna get sicker and sicker, and that means more readmissions.

-just my two cents.

[talaxandra]

The fact that I don't get regularly scheduled breaks does not justify not providing complete care to patients ~ and I'm not talking about the niceities that we wish we could do ~ backrubs, "being with" your patient, etc ~ I'm talking about something that not only are JCAHO and CMS mandates, but are publically reportable measures and liability issues in a BIG way.

So is that you think nurses aren't documenting education, or aren't conducting it? Because I haven't read any posts where members have said they don't think patient education is important, or optional, or "a nicety." What I have read is members saying that documenting patient education is not as high a priority as providing nursing care, and that the paperwork is often inappropriate for their area, time consuming, and redundant, and that assessing whether the education has been effective is not always possible.

It's just always easier to point fingers at the nursing staff rather than address the core problem.

:yeahthat:

[sjrn85]

It would also help if nurses who actually work the floors and do the pt. education would be involved in the development of pt. ed. tools, instead of the usual, where yet another form is thrown at the staff by yet another committee of people who aren't going to have to use it in daily practice.

[talaxandra]

It would also help if nurses who actually work the floors and do the pt. education would be involved in the development of pt. ed. tools, instead of the usual, where yet another form is thrown at the staff by yet another committee of people who aren't going to have to use it in daily practice.

Another excellent point, which is pertinent to pretty much every policy and documentation change.

[Q.]

If patient education has a history at your institution of not being documented, then this is a SYSTEMS problem, not a nursing problem. If better SYSTEMS including double checks etc. were in place (whether they be electronic or paper) then this would not occur. It's just always easier to point fingers at the nursing staff rather than address the core problem.

This is not always the case.

In my experience, it's actually easier to start thinking of new systems or design new forms or find new technology than it is to find out why people are documenting or not. Is it because of where the form is in the chart? Is it being forgotten? What? It could very well be a "SYSTEM PROBLEM" but who better to identify the SYSTEM PROBLEM than the system users?

My belief is that patient education IS being taught, but that it is not being documented or documented adequately. Numbers across the nation show about 40% or so documentation rates. Facilities that have electronic charting that is cumbersome, facilities that have electronic charting that is efficient, facilities that have one-page checklists all face the same issue. It's not being documented. And, rather than once again going back to the system and adding another paper, or a new paper, or purchasing yet another $80,000 system, I thought it might be a good start this time to ask the staff why they don't document- whether it's because they forgot, don't like the checklist, documented it elsewhere and not on the form, etc.

Ideally it would be AWESOME if staff nurses who actually used the systems would help to design solutions, but often times that doesn't happen, and those nurses in the backgrounds are left trying to muddle through these things by themselves, hoping they can fix the problem but often times not.

I'm hoping for some insight.

Tracy, great point about priorities, etc. and that is so true. It's a tough road. Everything that is being thrown at you to complete/do because it's someone's priority; yet at the same time that is my one sole priority. I can see how that can conflict. Now it's how do we figure out to address all of them?

[SmilingBluEyes]

Yep, that was what I was saying. Do a PI project and most importantly, *INVOLVE THE NURSES WHO ACTUALLY HAVE TO USE THE ED DOCUMENTATION TOOL * to design a system that works for them-----and you might be surprised how much improved this can become. Consider it a systems problem first, not just a nursing problem---involve all the disciplines in making things better, particularly those who must do the work, and you may actually get somewhere.

[SmilingBluEyes]

I hope I was able to give you some insight. A process improvement team can be formed, work out the bugs, and then maybe things will improve. Good luck.

[Q.]

What I have read is members saying that documenting patient education is not as high a priority as providing nursing care...

And that's precisely the issue.

[Q.]

I hope I was able to give you some insight. A process improvement team can be formed, work out the bugs, and then maybe things will improve. Good luck.

Deb, thanks for the suggestion, but we're actually well beyond that stage. A process team did look at this and came up with a solution. The solution isn't being used. And since it's a widespread issue, meaning across the nation, I thought this time we'd start with a general "feel" of what staff nurses are thinking with regard to the whole process in general.