Q&A: Documenting patient education

Q: How should we properly handle patient education when it comes to care plan assessment documentation?

A: It’s pretty common to see “canned” or non-patient-specific education categories in the record, such as orientation to the room and other generic information, checked off on a patient’s care plan related to education. Sometimes this is all you will see. Many organizations struggle to convert the information from the nursing assessment and plan of care to the education documentation section of the medical record. Since education is ongoing, doesn’t it make sense to incorporate it into a single interdisciplinary plan or care? Standard PC.02.03.01, EP 4, requires that education and training be based on the patient’s assessed needs. So simply work the process into what you are already doing.

Here’s a list of a few of the findings related to this education requirement, which will shed some light on what has been observed in patient records:

• There is a lack of patient education related to the isolation precautions implemented.
• The patient has a wound and there is no notation of skin issues being addressed.
• The patient has been in the hospital for 10 days, and there has been no education since the day of admission. The patient has postoperative complications.