do you put patient teaching in a nurses note?

caliotter3 · Apr 25, 2011

Yes. We are required to show this in our nursing notes in home health. Don't go into detail, just mention the subject and the results of the teaching, to show that it was done.

HouTx, BSN, MSN, EdD · Apr 25, 2011

Rules about charting are made by the facility in which you work. You will need to refer to your employer's policies and procedures for the answer to this question.

psu_213, BSN, RN · Apr 25, 2011

Yes! We actually have a section in the "discharge" part of the chart for pt teaching. If a patient suffers injury due to their not doing something at home that was taught to them in the hospital, then it can 'come back' on the discharge nurse not confirming (and charting) the he/she verified that the pt understood the teaching.

gentlegiver, ASN, LPN, RN · Apr 25, 2011

It just makes sense to chart what you taught and how well the pt learnt the lesson, also if the pt is having difficulty in certian areas it's a good idea to have it written down so they can't come back and say you didn't try to teach them, and what you did to help them understand what they needed to do.

noregrets · Apr 25, 2011

Joint Commission requires education charting. We do it in the care plans.

KBRN413 · Apr 25, 2011

We do all of our charting online now. We have a section in our nursing shift assessments that states "nursing education". We talk about what we taught the patient and family, if they understood the teaching and if reinforcement of that education was necessary.

merlee · Apr 25, 2011

Aside from the obvious, that you taught and it was understood, charting also helps others to see how you are utilizing your time.

As nurses, we are constantly teaching - at least I was! - and we rarely take credit for the time we spend doing it. Aside from formal teaching about disease processes, we explain procedures, talk about their meds, skin care, repostioning, etc, etc. And we hardly have time to chart all of it.

We tell them about their wound care, how to avoid getting infected, and why they need to ask their friends and family not to visit if THEY are sick!

So the answer here is a resounding YES YES YES you must chart about your teaching.

wilsonbl5150 · Apr 25, 2011

Absolutely, if it's not in the chart then it didn't happen

TinyHineyRN · Apr 25, 2011

Our charting program generates an education flowsheet based on the care plans we enter. We use that flowsheet to document education topics, who we educated (pt, family, etc), modes of education (verbal instruction, handouts, return demonstration, etc), and response to education.

allnurses Guide · Apr 25, 2011

Yes, we must do that in home health as Caliotter mentioned. It's one of the most important things to chart because it is one of the reasons the state will pay for skilled nursing hours. If the patient is a child we have to document teaching to the parents or primary caregiver.

TopazLover, BSN, RN · Apr 25, 2011

I have reviewed numberous charts and have found nurses are usually very good about documenting teaching about the obvious medical issues and nursing conditions they treat. The clearest example of missing the boat that I find is anything to do with psychological health. Examples of this would be impact of chonic illness, depression, lack of understanding of use of antidepress. drugs and use of anti seizure meds for mental health issues.

Even when these have doctors' orders that must be taght I find little real teaching being documented. ?These issues can bring the patient back in time and again and even earn them a reputation as a freq. flier. Many times these admits could be avoided if education had been complete.