Guest Author - Julie Reeser, RN
How many of us have heard the adage, ďIf it isnít documented, it isnít done?Ē All of us, right? So, then, why do so many of us leave out documentation of education? It is a standard of practice expected by the Joint Commission and the ANA. One hallmark of professionalism is accountability. Documentation is your accountability. It is what separates you from the non-professional and holds you responsible. Taking the time to document the efforts you have made at including your patient and their families in the plan of care will also help you focus your nursing care toward the subjects that have the most impact on outcomes and lifestyle changes.
When you give a cup of medications, do you know what you are giving? Have you thought about why that particular patient is receiving those particular medications at that particular time by that particular route at that particular dosage? Since you have, then why not talk about one of them when you administer it? Your dialogue would reflect your professional role, establishing a sense of trust and knowledge between you and your patient. When you offer a cup of fresh water to your patient, do you remind them that you are documenting how much they eat and drink? When your patient hurts and you ask them the score on your institutionís pain scale, do you document that as education? These are all examples of how we are already doing the work, but not giving ourselves credit for it.
If you have documentation by exclusion, then your facility probably has a computerized flowchart for education documentation. An example would be a box where you choose from a drop-down menu of topics covered such as safety, medications, or treatments. Then the next box would include the way you taught, such as verbal, written, or demonstration. Documentation of who was taught the information should also be included. The last component is how the education was received. Did they ask questions, verbalize understanding, or were there barriers to learning such as denial or severity of illness? All of these pieces follow the flow of your care. You assessed the need for education, the willingness of the learner, who was learning, and how they received the knowledge you imparted. This is the information required by your professional licensure and should be documented for each patient, every shift.
We are shortchanging our own profession when we think that it is less than important to document education. This is what we went to school to learn to do. Anyone can push pills and change dressings, but only a professional can educate and change lives. You have the opportunity to empower your patients and improve their outcomes and quality of life.