DOCUMENT OUTCOMES OF HEALTH EDUCATION ACCURATELY AND COMPREHENSIVELY

Topic Outcomes:

A. Discuss the purposes of documentation

B. Identify and explain the steps for effective documentation

Topic outline:

1. Purposes of Documentation
2. Steps for Effective Documentation

Providing health education is an important element in the prevention, management of

different illnesses and rehabilitation. Proper documentation of the education activities is
a way to monitor patient responses and additional educational needs.

Documentation is done for several purposes. Documentation promotes communication

about the patient’s progress in learning among all health care team members. Good
documentation helps maintain continuity of care and avoids duplication of teaching.
Documentation also serves as evidence of the fulfillment of teaching requirements for
regulatory and accrediting organizations such as the JCAHO, provides a legal record of
teaching, and is mandatory for obtaining reimbursement from third party payers.
Documentation of patient teaching can be done via flow-charts, checklists, care plans,
traditional progress notes, or computerized documentation. (Rankin, S.H., & Stallings,
K.D. 1996)

Five Steps for Effective Documentation

Continuity and consistency of care, improved efficiency, and decreased professional liability are
all benefits of documenting patient education Here are five things you as a healthcare professional
should do to ensure proper documentation:

1) Use a standardized form. Standardized forms, sometimes called “teaching tools,” have
designated areas for specific information and can be an efficient way to quickly find important
information. While they may have certain drawbacks resulting from multiple contributors,
abbreviations, and limited space, they still have major advantages over narrative progress notes.
In addition to providing an easy way to scan for information, forms also have designated areas
to highlight key concepts, such as learning preferences, communication barriers, curriculum,
responses, and further teaching needed. Making use of these areas will help ensure continuity
in the education process.

2) Document formal and informal teaching. Formal teaching is often thought of as

curriculum that is taught at a designated time, perhaps prefaced by a clinician saying, “Now I’m
going to teach you about….” Informal teaching, on the other hand, is teaching that happens on
an on-going basis. For example, when Annie and Bob are feeding Claire, they are taught how
to burp the baby, provide proper head support, and assess if she has a swallowing problem. Both
formal and informal teaching are essential to patient education and should be documented in
the chart.

3) Describe the response of the learners. Patient education is more than what the clinician says
or does; patient education is what the learner learns, and this should be carefully noted in the
medical chart. In addition to a brief description of the topics covered, documentation should
include a note about the interaction/response of the learner. In the case of Annie and Bob, this
would include notes such as “Mother described…,” Father demonstrated…,” or “Parents asked.…”
Patient education documentation should include information about the learner’s reactions and
feelings as well as responses to open-ended questions.

4) When possible, put copies of educational materials in the chart. Ideally, copies of the
actual teaching materials should be included in the medical record, says Haber. If it is not possible
to put in the actual documents, describe the materials that were given out and encourage the
patient or family to show them to their other clinicians. Detailed information about the teaching
materials helps with the continuity of care, avoids unnecessary repetition, and helps to build on
lessons already learned.

5) Update the teaching plan. As patient education is an ongoing process of learning and
teaching, the patient’s medical chart should include space to update the teaching plan and
include information about further learning needs, effective teaching techniques, and
recommendations for the next steps. With this updated teaching plan, clinicians have the tools
they need to educate patients, and patients remain stimulated and challenged by learning new
information they most need to know.