Inclusive spirit promotes documentation teamwork
Get all disciplines involved in creation of forms
Q. How do you work with disciplines other than nursing to motivate them to join your efforts of documentation for patient education?
A. It’s important to establish a team atmosphere for the entire education process. "Our care system is entirely multidisciplinary from the time the patient is admitted to the hospital until they leave. We are working across department lines as one seamless health care provider," says Jeanne Ryan Town, BSN, MS, MEd, director of educational services at Holy Family Hospital in Spokane, WA.
To work as a team, one multidisciplinary documentation form for patient teaching should be created. It is difficult to know what has previously been taught if each health care professional has to flip through 40 pages in a chart to find the documented education for each discipline, explains Ryan Town. "If disciplines only document in their own area, they won’t be aware of the total patient picture," she says.
A single documentation form creates a convenient communication tool, agrees Marie Muskovin, RN, MSN, director of education at Lexington (NC) Memorial Hospital. With one form, a respiratory therapist can quickly see that a patient has watched a video on asthma and can review that information during treatment. Or if the patient seems confused about dietary restrictions, yet the documentation form indicates dietary teaching took place, the nurse or other discipline can notify the dietitian.
To make sure the form fits the needs of all disciplines, have a representative from every area sit on the committee assembled to create the form, advises Mary Wolcott, MSN, patient education coordinator at Methodist Hospital in Omaha, NE. Often, a team of nurses will create a document and then ask staff in various disciplines a few questions about design and content. Involvement is what’s needed. "All disciplines need to be involved in the whole process of the development and implementation of the form. When you work that way, they have a vested interest in the project because they have contributed to it. It encourages documentation," says Wolcott.
To improve documentation for all disciplines, including nursing, make sure the form is efficient. At Lexington Memorial, disciplines don’t have to write many observations long-hand. Common teaching assessments such as patient understanding or readiness to learn are coded. Also, the education form is kept at the patient’s bedside so it is within easy reach, says Muskovin. (For an example of the interdisciplinary patient education record used at Lexington, see pp. 71-74.)
Once the documentation tool has been created, have each department introduce it, advises Mary Loftus, RN, BSN, CDE, patient education coordinator at Nyack (NY) Hospital. "We used our interdisciplinary patient education committee to introduce an interdisciplinary patient teaching form and obtain backing for it," she explains. "In some cases, I attended the department meeting to inservice them on the use of the form."
Also, once the form is implemented, listen to the staff in various disciplines who document patient education when they offer suggestions on how to make the form more functional, suggests Loftus. For example, after the form was in use, a staff nurse mentioned that sometimes the only education that can take place covers safety issues, and there was no such category for documentation on the form. The patient education committee amended the form.
Although involving all disciplines in the development and implementation of a documentation form helps promote its use, those methods are no guarantee that the form will be used consistently. Each person responsible for educating patients must be held accountable for documenting the teaching. Make it a part of their job description and yearly performance evaluation, says Ryan Town. If the employee is new, learning how to correctly document patient education should be part of orientation and part of the orientation competency assessment skills checklist, she says.
Also, the documentation form should clearly indicate who is responsible for the teaching and documentation, says Wolcott. For example, if the therapist is responsible for educating a patient about walking with crutches following knee surgery, it should be clearly stated on the form.
Once accountability has been established, periodically conduct chart audits to make sure all disciplines are documenting patient education. Supervisors for the disciplines who are not documenting should be notified because failure to document teaching could put the hospital at risk. "Disciplines need to understand that if patient education is not documented, it is not done. They need to know that it is a legal issue," explains Wolcott. If the hospital is sued, documentation helps provide proof of education when a patient insists he or she was not told.
While people who do a poor job of documenting patient education need to be disciplined, those who do an excellent job should be rewarded. Loftus gives awards for documentation of patient education each November during Patient Education Week.
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