By Annette R. Karnash, R.N., M.N.
Documentation is the window through which 3rd party payers and intermediaries view the care that patients receive. The picture painted by the nurse’s documentation determines whether payers perceive the care as reasonable and necessary.
Patient education is a complex nursing skill that includes each step of the nursing process. Should we fail to document these, third parties may question the need for care, especially out-patient visits when patient education is the primary intervention. The omission of significant data that supports the need for patient education may indicate to others that education is unnecessary, ineffective or repetitive. The failure to make a definitive outcome statement that ties patient education to symptom control or inadequate documentation of the patient’s response to teaching, may fail to provide an adequate basis for future teaching.
The need for patient education should be documented. The extent and nature of the patient’s knowledge deficit and how that deficit affects functional ability and symptom control needs to be documented. The educational profile, such as the patient’s educational level of sensory deficits, learning style, should be noted.
The outcome of the education includes what you expect the patient to know by the end of the teaching session and what skills need to be learned in order to perform.
The specific actual teaching and the methods used (group, individual, charts, A-V’s hand outs, tapes, demos) should be documented.
And finally, what knowledge and skills has the patient attained based on those that were identified or expected outcomes? What changes have occurred in functional ability and symptom control? This evaluation gives justification for what additional needs the patient may have for future encounters, if any.
By providing clear, measurable, observable goals, with proper documentation, the risk of denials for patient will be substantially reduced.
