How documentation outcomes guide the way: a patient health education electronic medical record experience in a large health care network.

BACKGROUND

Despite Joint Commission on Accreditation of Healthcare Organizations' standards in patient health education (PHE), the patient education process oftentimes remains underreported in many patients' medical records. The primary focus of this project was to create a usable electronic medical record (EMR)-based method of documentation of PHE within a large Department of Veterans Affairs (VA) health care network using clinical staff involvement, routine monitoring, and consistent feedback.

METHODS

A team of clinical staff was formulated to review current literature, seek out best practices, examine existing VA PHE templates, and create and monitor a user-friendly EMR process for documenting the assessment of patient learning needs and the outcomes of teaching and education. Professional team focus groups, pilot testing, usage monitoring, local action planning, and feedback surveys were selected strategies utilized to create and evaluate success and make timely revisions. RESULTS/RESPONSE: Monthly usage reports were provided to the local PHE teams. An EMR monitoring system for clinical reminders provided an appropriate and tested mechanism to collect specific usage data. Since 2003, steady improvement has been reported with use partly due to greater acceptance of the process and growing competition among network sites. The newly created PHE EMR has since been modified to enhance the quality of documentation as staff becomes more adept at using these tools.

CONCLUSION

Staff involvement in format design and development combined with consistent feedback and evaluation resulted in improved documentation compliance. Future work is focused on the quality of evaluations of patient learning needs and electronic recording of patient teaching and education.