do you put patient teaching in a nurses note?

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im not sure about this... thanks! :)

Specializes in Sub Acute Rehab/ Oncology Med-Surg.

Some facilities have a checklist, however, if the teaching is related to risky AND safety behavior (falls, DM teaching, etc), I would defiantly write a short note. Doesn't hurt to cover your behind twice!

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Specializes in Med-Surg Nursing.

Yeppers, I sure do!

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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.

Putting it in your notes from the get go beats being called to the office to redo your notes. One of my nursing directors said if we don't show teaching, the shift might not be paid.

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Specializes in LTC Rehab Med/Surg.

Most of us chart teaching without a second thought. It's a matter of protecting your license. "Fighting" with a pt about a fluid restriction. Encouraging a pt to use the call light when walking to the BR r/t weakness. Acid reflux? Put the head of you bed up ............ I never considered it teaching til I read this thread. I just thought I was covering my butt.

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Absolutely.

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Does anyone have any samples of how to correctly document teaching?

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