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Patient education and documentation under the JCAHO microscope

Ambulatory Safety Monitor, February 26, 2003

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JCAHO surveyors focused on documenting patient education when they visited McLaren Medical Management Inc. in Flint, MI, for a recent survey.

"We had documentation in the medical record, but the surveyors found that they had to search for this information," says Denise Dach, MBA, RHIA, McLaren's performance improvement and compliance director.

For example, when McLaren's staff instructed patients about the potential adverse effects of medication, they document it. But they don't record this information in a consistent place on the chart. Some caregivers jot notes on the bottom of the record, while others write in the history and physical portion of the record. Thus, surveyors had to hunt for evidence that staff spoke to patients about medications.

The surveyors also said that staff should be more specific in their notes about the patient education they perform. Writing "gave out materials" was not specific enough. Instead, staff learned to write, "gave materials to John Doe about the side effects of Demerol."

Remember, using a stamp to signify that staff delivered patient education materials is also insufficient in the eyes of the JCAHO. Surveyors wanted to see comments about the patient's level of understanding.

"They said that education is critical for well-baby checks," says Bernadine Baumann, RHIA, McLaren's manager of ambulatory patient information services. "They want to see in the record what kind of information staff give parents at each interval of the child's development."

TIP: Create educational childcare packets that include age-specific information about immunizations, prenatal care, nutrition, diseases, preventive care, and medication. Make them readily available to your patients.

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