The case study begins with the patient’s emergency transport and ends with his discharge from services. Patient missed her last appointment due to schedule conflicts. This resource contains strategies and examples for crafting patient education documents. Found inside – Page 318For example, document any alternative treatments that the patient is performing, ... and coordination of care, patient education, and direct interventions. Instructions for presenter-directed activities: Use this five-column format to provide documentation of Educational Criteria: C. Objectives, D. Content, E. Time Frames, F. Presenters/Content Specialists, and G. Teaching Learning Strategies to show that the activity supports the purpose/goal(s). Worsening Bladder and Bowel Incontinence Patient is a 69-year-old, English speaking, female living in a senior living facility by herself. In 2005, patient had a car wreck and his right tibia got infected (osteomyelitis) and 3 inches of the bone was removed in 2005 during the hospitalization, post-accident. Patient went in into the hospital on 05/20/2011 for a stroke. Service charges will appear from Pear Solutions, LLC on your billing statements. Patient wanted the HHA to start coming next week. Patient also is having an exacerbation of MS, as the symptoms suggest, secondary to noncompliance with Avonex. Multiple falls 5. Taking a Deep Dive into Care Plans and Patient Education Documentation And by having access to our ebooks online or by storing it on your computer, you have convenient answers with Examples Of Patient Education Documentation . No wounds noted currently. You should be having the patient teach back the essential content (self-care skills, signs of a problem, what to do if those signs occur). … skilled services provided (e.g., materials and strategies, patient/family education, analysis and assessment of patient performance, modification for progression of treatment); session length and/or start and stop time, as required. ISSUES AND TRENDS (3) There have been successful lawsuits alleging that nurses pro vided substandard patient educa DOCUMENTATION OF PATIENT tion [2]. Patient presented with burning, frequency, and urgency around 08/14/2011 and was seen by Dr. A on 08/16/2011. This helps in making the nursing note documentation quicker and easier. 2. Diet/Nutrition Document the type of diet the patient … Patient reports compliance with medication intake. The preprinted interdisciplinary care plan is an effective tool in increasing the documentation of patient teaching onto the patient education record; however, when combined with praise and chart audits, the preprinted document becomes even more effective. Patient was discontinued on Nifedical XL and was started on Amlodipine during the last certification period. Patient was stabilized. RN currently is not aware of the dosage on the insulin. The falls were uneventful though. Patient probably is losing fluid secondary to the ostomy. Additionally, the source pays special attention to pamphlet organization and patient terminology. She was there until 04/18/2012 and then, went to YYY Rehab on 04/19/2012 and came out on 04/29/2012. (Skilled terminology is highlighted in red.) 4) When possible, put copies of educational materials in the chart. This helps in making the nursing visit note documentation quicker and easier. Patient reports he turned diabetic recently. NTG patches discontinued. Patient arrived at therapy with 3/10 L hip pain. Patient is dependent on ADL and IADL performance and caregiver needs assistance. 469-810-6022 | pearsolutionsllc@gmail.com, Copyright © 2017, Pear Solutions LLC. Some rigidity of posture with limited ROM is evident. No other infections reported in the last 2 months. Interview staff to determine what barriers there are to documentation of patient education, advises Villejo. Most nurses are not aware of legal concerns that could arise from inadequate education and care plan documentation. Download Free Examples Of Patient Education Documentation volume, based on lectures given by the author at The Fields Institute in fall of 1995, explains and illustrates the basic concepts of bordism characteristic classes, Adams spectral sequences, Brown-Peterson spectra, and … Patient’s other health history includes HTN, DM2, aortic valve regurgitation, congestive heart failure, hypothyroidism, seizures, hypercholesterolemia, GERD, and anemia, and osteoarthritis. Patient reports that she tries to keep up with required fluid intake, but sometimes slips off on it. Patient was later taken to YYY rehab. Patient education is a key component to disease management, convalescence, and overall wellness maintenance. For example, one problem at MD Anderson was the form’s location. Patient has a very poor coordination on walking. Patient does not report any bothersome nausea and vomiting for now. No falls reported in recent times. This study indicates that reinforcement in … EDUCATION DOCUMENTATION FORM. Privacy Policy Within the Institute for Patient Care Effective Documentation of Patient and Family Education Overview: The diagnosis of “knowledge deficit” must be included by the nurse on every patient’s Common Patient Problem Intervention Outcome sheet on admission and specify the area of the deficit (i.e. Found inside – Page 37Many higher education institutions prefer staff to convert files into the standard portable document format (pdf), so that they can guarantee all students ... To get started finding Examples Of Patient Education Documentation , you are right to find our website which has a comprehensive collection of manuals listed. Found inside – Page 145Documenting the patient - teaching plan Several forms are available for documenting ... ( for example , Deficient knowledge related to low - sodium diet ) . 1. A social worker is seeing him shortly to facilitate his insulin getting filled. Caregiver reports patient having a fall in December 2011 and she is at significant risk for fall. The incontinence has not deteriorated from the last assessment period, but has not improved any either. Found inside – Page 129... format. objective: The portion of the SOAP note where the patient data are recorded; also includes treatment provided including patient education and/or ... Patient reports diffuse spasms and shooting nerve pain in the limbs. Patient was diagnosed with UTI and was started on SMZ-TMP 800/160 mg 1 tablet twice daily, on 08/16/2011. Patient reports that this habit of hers probably resulted in her developing the current UTI she is having. Patient is a 69-year-old, English speaking, female living in a senior living facility by herself. Use a highlighter on key points in … The patient will receive education and training specific to the patient’s needs and as appropriate to the care, treatment and services provided. Found inside – Page 108It also ensures patient education , continuity of care among team members , continuity of information , improved quality of patient care , reduced length of ... Actual written educational material given to the patient included with the chart. Patient is a known case of Meniere’s disease and had a shunt procedure for inner ear about 20 years ago. Procrit shots continuing every Wednesday. Examples Of Patient Education Documentation This is likewise one of the factors by obtaining the soft documents of this examples of patient education documentation by online. Found inside – Page 122The ideas and principles of, for example, pedagogical documentation resonate with these discourses. In addition, as a consequence of political and ... We offer customizable skilled nursing documentation templates for Start of Care, Resumption of Care, Recertification Evaluation, 60-Day Summary and Discharge. If there is a survey it only takes 5 minutes, try any survey which works for you. Choosing effective patient education materials. Several examples of forms for care plans, assessment and documentation can be found on the Found insideExamples of such work can be seen in the videos Einblicke I and II, which give a good ... 3 9 At the 3”' Dance Education Biennale in Frankfurt, for example, ... Findings from a physical examination. Patient started having chemo in February 2011. She has a stooped posture on standing. RN called the XXX specialty pharmacy at 1-xxx-xxx-xxxx at xx: xx and spoke to the customer care representative YYY regarding the refill. The narrative is generated once you click the Submit button at the end of the page. • In order for there to be a standard process for documentation it is required that there is appropriate education and support to the staff who will be performing the documentation. Ideally, copies of the actual teaching materials should be included in the medical record, says Haber. Agree with the patient on realistic learning objectives. This section provides guidelines for documentation of patient education on the Interdisciplinary Patient Education Record. Patient Education Reports the current economic environment. Next session of chemo is on 04/23/2011. 2. Patient is being scheduled for an evaluation on this for an E.N.T. List some methods of documentation of patient education. The RD will find that the ADA Evidence-Based Nutrition Practice Guidelines provide resources to enable RDs to meet the following documentation essentials. Found inside – Page 43In addition, state regulations pertaining to patient education are published and enforced under ... physical, and respiratory therapists, for example. Initially, he was managed on IV antibiotics and then, oral. Please visit OASIS Discharge Template, To access our database of Patient Teachings and Customizable OASIS Assessment Templates for Skilled Nursing Documentation, please Sign UpÂ, Monday – Friday 8:00 AM-5:00 PM CST The skin on the abdomen has some erythematous spots that probably were the drainage sites, when the infection was active. Open Notes: Doctors and Patients Signing On | Annals … annals.org/article.aspx?articleid=745909 Motor power BUE has improved over the last 2 months with the therapist intervention. XD. Nursing services are needed twice a week for colostomy bag change. 2.) so many fake sites. Please visit OASIS Discharge Template, To access our database of Patient Teachings and Customizable OASIS Assessment Templates for Skilled Nursing Documentation, please Sign Up, Monday – Friday 8:00 AM-5:00 PM CST Found inside – Page 107Criterion 9 : Recreation Service provides ongoing patient education programs Example : Indicator 1 - There is documentation of leisure education programs of ... Diastolic pressure has been within limits defined for the most part in the last certification period. Found inside – Page 52... sheet for the documentation of patient teaching to accommodate all teaching activity regardless of subject . For example , all of our existing protocols ... A patient education form present on the chart with a check box listed for each of the 5 components AND documentation, (e.g., "X")that each component was reviewed with the patient/caregiver (actual written material given to the patient … Proper Documentation Example #1: 03/21/14 0815 Dr. J Smith notified of change of status r/t abdominal pain, absent bowel sounds. This practical reference provides theory-based approaches to patient teaching in a clear and concise format. Guidance is presented for teaching patients of all ages and their families and the book covers a variety of health care settings. An additional Patient and Family Education Continuation sheet is added as needed for detailed documentation. Caregiver reports the patient to have had a total of 2 falls in the last 2 months. Patient is an 80-year-old female who was admitted to XXX for rectal prolapse and patient had surgery on 04/12/2012. For any queries, please contact us 469-810-6022, Home Health Recertification Assessment Template, Complications of Recurrent Lupus Activation, Safety Instructions for Parkinson’s Patients, Home Safety Measures for Alzheimer’s Patients, History and Physical Examination Examples, Uncontrolled Blood Pressure with Medication Changes. ‐‐‐‐‐‐‐E. Patient had no colonoscopy and prostate exams in the last 2 months. The book is organized into two basic sections - the first describes the theories and process of learning and teaching, and the second focuses on the major fields of patient education practice in place today. Patient has a past medical history of Patient is a 72-year-old male patient who lives with his spouse. Patient compliance is the level at which the patients’ conduct or behavior adheres to the clinician’s advice and subscribe to the authority of the healthcare professional. The oral antibiotics are still continuing. This assignment is to be submitted as a Microsoft Word document. Found inside – Page 106For example, if teaching a patient therapeutic exercises for his or her shoulder to perform at home, document the exercises you are teaching the patient, ... Patient is at increased risk for fall. Patient for the most part is limited to her wheelchair needing maximum assistance to assume a standing posture. In this book, the Institute of Medicine makes recommendations for an action-oriented blueprint for the future of nursing. Diffuse body aches, spasms, with left eye pain, and increased frequency of incontinence of bowel and bladder reported. and document the care/education provided was an issue. Patient’s surgical history includes 2 colon resections secondary to diverticulosis and a hysterectomy and bilateral oophorectomy. Found inside – Page 70Provide direct patient care , conduct health education interventions for ... A sample of hier patient education documentation is shown in Figure 3.9 . this is the first one which worked! Documentation of Medical Records Introduction: • In a continuous care operation, it is critical to document each patient’s condition and history of care. Found inside – Page 102Which is an example of appropriate documentation of patient teaching? a. “Teaching done on diabetic foot care.” b. “Instructed on washing and drying feet, ... Our OASIS templates generate customized narratives for individual patient needs with few clicks. RN was told that they will reach out to the patient on the issue today afternoon. •Indicate changes in patient’s status or any observed changes during or after treatment. For example, to accommodate the needs of a dietitian, there must be a place to document teaching about the patient’s diet. I did not think that this would work, my best friend showed me this website, and it does! Patient presented with a temperature of 99.4 today. Exacerbation of Multiple Sclerosis 2. 1. You can generate admission assessment summary similar to home health paperwork example in this post using our customizable OASIS templates. Our OASIS templates generate customized narratives for individual patient needs with few clicks. Also, patient is forgetful with regards to use of her assistive device despite repeated instructions. Small bruise that is in a healing stage noted on the forehead. appointment shortly. Privacy Policy You may include objective observations about how the patient appears from the end of the bed. Patient reports that his HbA1c was not that elevated. Page 1 (of 4): Showing records 1 - 50 (of 184) Radiation to the Pelvis (male) Discharge Instructions (External Beam) More Details... Ablation Discharge Instructions. This book provides the nurse with an up-to-date, complete, and practical guide to planning, implementing, documenting, and evaluating patient education to ensure its effectiveness and appropriateness. Patient Education and Counseling, 9 (1987) 81-90 Elsevier Scientific Publishers Ireland Ltd. Patient had 2 units of transfusion in the last 2 months. Occasional constipation still bothers her. Found inside – Page 171Patient Education Common Mistakes Students Make When Documenting Objective ... what they did and not how the patient responded or performed—for example, ... Uncontrolled Blood Pressure. Policy: Education helps patients gain knowledge and skills in order to meet ongoing health care needs. Patient was taken to ER at XXX. The Diabetes Literacy and Numeracy Education Toolkit (DLNET) was designed to aid in the education and self-management of patients with Type 1 or Type 2 Diabetes regardless of their current medical regimen or health status. Found inside – Page 91Physician : Let me see if we have some free samples of Bactrim DS . ... DOCUMENTATION OF PATIENT TEACHING Communication between members of the health care ... Patient also reports pain in the left eye. Many thanks. • To ensure the patient receives the best available care, the information must be passed among all members of the interdisciplinary team of caregivers. Reason(s) for Home Health Recertification. No family history of cancer. Sample answer . Motor strength all over noted to be weak. The patient also had another fall in September 2010, but without any injuries. Thorough revision includes a stronger clinical application focus and strong practice examples. The text highlights the patient education process and stresses collaboration among health care team members. No deviation of angle of mouth noted. Documentation is also essential for verifying the quality of care delivered and determining outcomes of care. UTI. Poor Motor Coordination 4. Patient was noted to be noncompliant with walker use. Patient was instructed to practice deep breathing to prevent areas of atelectasis and lung collapse in the basal areas. The Interdisciplinary Patient and Family Education Record provides a central location for documenting patient and family education. This post provides home health paperwork example for writing assessment note for Recertification Evaluation in home healthcare setting. Use terminology that reflects the clinician's technical knowledge. Service charges will appear from Pear Solutions, LLC on your billing statements. Patient is a 75-year-old pleasant woman with history of Parkinson’s disease with markedly limited ROM, osteoarthritis involving low back and bilateral hips. Physical therapy documentation is an important tool for recording therapy treatments and tracking a patient’s progress. Stimulate the patient’s interest. Toes still dragging on the floor. All Rights Reserved | This website is a property of Pear Solutions, LLC located at 539 W. Commerce St #3412 Dallas, TX 75208 . Patient saw his PCP, Dr. B also last week. Patient requires assistance with administration of Avonex IM injections weekly and is unable to safely administer the shot herself due to poor fine motor control in her hands and low vision. Phantom limb pain complained in the RLE stump. More Details... Abscess: Patient Education after Dalbavancin. States he has not been able to sleep in spite of Seroquel, and agrees to a dosage increase. Requests for non-prescriptions/herbal medications by the patient, condition patient is treating and recommendations made for treatment Any information/education given to the patient that is in addition to the accepted standard of care . To help therapists and assistants improve their documentation, the following are examples of documentation that clearly demonstrates the skilled nature of therapeutic exercise. • Research Documentation needs to promote collaboration and communication between all clinicians involved in the patient’s care. Packed with colorful images and clear-as-day guidance, this friendly reference guides you through meeting documentation requirements, working with electronic medical records systems, complying with legal requirements, following care ... CHECKLIST FOR PATIENT EDUCATION DOCUMENTATION. Patient reports that after having his surgery (panniculectomy) and removal of tissue, he was told that he might not be a diabetic and might not need insulin. Once you have assessed your patient's needs, concerns, readiness to learn, preferences, support, and possible barriers to learning, you will need to: Make a plan with your patient and his or her support person. Patient came out of YYY Rehab yesterday. RN made sure the medication was in her MedMinder. To illustrate these points, the case study follows a patient’s course of treatment through several medical services and the respective provider types furnishing the services. as needed from a referring physician’s office (for example, physician order, notes to support medical . lol it did not even take me 5 minutes at all! Found inside – Page 45The sample patient teaching guide in Figure 3.3 is one example of good documentation . As mentioned in the previous chapter , it is important to develop ... So, preauthorization form for Avonex was not signed. Found inside – Page 67Documentation Error: Blaming or Disparaging Another Provider in the Patient Care Record ... and patient education about the postoperative exercise program. Provides a framework for nurses to use in ethical analysis and decision-making. Poor coordination of muscles of BLE with poor balance, thus making the patient more prone to fall. Hemoglobin is reportedly improving. Patient is currently on Minocycline 100 mg twice daily. Which of the following documentation examples will meet the stroke education measure: 1.) Patient’s problems with balance continue. Document patient education. This handbook will enhance your ability to gather the right information the first time--and every time Author Colleen Garry, RN, BS, has compiled case studies that document best practices and reference several different CDI models so that ... Found inside – Page 173A good example of this was the JCAHO initiative to improve the documentation of patient and family teaching . Before the initiative , documentation of ... Constipation is being well managed. Mild resting tremor, due to secondary parkinsonism is +ve. Patient to continue antibiotics for 2 weeks and reports compliance with medication intake. Spending time addressing challenges will yield desired documentation outcomes. This practical text/reference provides theory-based approaches to teaching patients of all ages and their families in a variety of healthcare settings. patient education, equipment provided, etc. Patient’s activity improved in the last 2 months with the patient being ambulatory from the state of being chairfast. Documentation of patient education. No complaints of diarrhea, reflux or constipation reported. Documentation is one form of communication and is a necessary part of medical care. For any queries, please contact us 469-810-6022, Home Health Recertification Assessment Template, Complications of Recurrent Lupus Activation, Safety Instructions for Parkinson’s Patients, Home Safety Measures for Alzheimer’s Patients, History and Physical Examination Examples. Found inside – Page 135explain what causes the patient's condition . For example a patient - teaching plan on hypertension would include a simplified lesson on the dynamics of ... Found inside – Page 56Examples of information included in the nursing history are patient allergies, ... When documenting on a patient teaching record, it is important to be ... Found inside – Page 209Was the education provided in a language and format the patient understood and was there documentation of the patient's understanding? The Record is double sided and has a purple stripe on the right side. Patient came out of XXX on 06/06/2011. BLE are still weak. Quality documentation consists of discharge planning and discharge information. Choose one (1) of the three (3) case scenarios and document patient education on the Interdisciplinary Patient Education Record. This format is required. Found insideThe patient-teaching certification is a checklist that indicates that the instruction took place. Most documentation begin with the type of therapy or ... Caregiver reports Meniere’s disease could be reverting, as it is 20 years since he had the shunt for inner ear. Write a short (50-100-word) paragraph response for each question. knowledge deficit r/t po anticoagulation use). Patient is on Omeprazole for GERD. The We have listed the reasons for patient’s admission assessment and based on those reasons we have built a summary which will explain and justify the need for admitting the patient to home healthcare services. Cultures were performed on the patient and patient was later admitted to the floor with antibiotics. Patient had multiple weeping sites on the abdominal skin. RN also called Dr. A’s office for follow-up on preauthorization. STAT Abdomen series x‐rays ordered and resident placed NPO,. SAMPLE: Health Education Protocol . Found inside – Page 100Thorough documentation is critical in justifying the need for service. ... Patient education is an important adjunct to therapeutic recommendations. Found inside – Page 296This chapter gives a brief overview of electronic documentation and common ... For example, including information in the chart about patient education ... He is currently started on Novolog insulin. Home Health Paperwork Example 1. GERD is still an issue. To make sure the documentation form met everyone’s needs, it was designed by the multidisciplinary patient education committee … Patient reports pain in the right knee, as he landed on this knee when he fell on 05/20/2011. Patient’s passive ROM in both upper extremities appear to be WNL. lack of documentation of patient education or discharge instructions entries made with different ink or pen (if the record is handwritten) the statement "Completed an Event Report," which can serve as a red flag that something went wrong during the patient's care. Terms & Conditions Patient also has family history of cancer and one sibling died of breast cancer with metastases to bone. Phone: 469-810-6022 Current episode started on 02/26/2011with the patient demonstrating constitutional symptoms of infection. necessity) or from an inpatient facility (for example, progress note). Upon request for a review, it is the billing provider’s responsibility to obtain supporting documentation . Email: pearsolutionsllc@gmail.com. Reports stabilization of GERD. Common pitfall: Not enough detail provided about specific ... Work on Quality of Documentation Examples This issue of Nursing Clinics of North America will focus on Patient Education. The narrative is generated once you click the Submit button at the end of the page. This  summary could be copied and pasted into the comments section, if you use an EMR software, or copied and pasted onto an addendum sheet that you can attach to the OASIS form if you use paper documentation. Found inside – Page 279Omdahl's article provides specific examples of appropriate documentation . Examples of home care services that specifically involve teaching can now be ... We have provided a demo OASIS assessment template where you can generate discharge summary using selection options provided. Found inside – Page 140Table 6–3 shows a sample patient education record. Documentation of patient teaching must include the patient's response to the teaching. Found inside – Page 74Revealing and Reflecting on High Quality Learning and Teaching Joao ... Museums, these authors suggest, offer a good example of documentation when they ... Indicate the This  summary could be copied and pasted into the comments section, if you use an EMR software, or copied and pasted onto an addendum sheet that you can attach to the OASIS form if you use paper documentation. More Details... Acetazolamide (Diamox®) CT Brain Perfusion Scan Discharge Instructions. We have listed the reasons for patient’s hospitalization. Examples Of Skilled And Unskilled Treatment Notes: All documentation should reflect skilled services. Finally I get this ebook, thanks for all these Examples Of Patient Education Documentation I can get now! We offer customizable skilled nursing documentation templates for Start of Care, Resumption of Care, Recertification Evaluation, 60-Day Summary and Discharge. We have listed the reasons for patient’s recertification need and based on those reasons we have built a summary which will explain and justify the need for continuing the home healthcare services for the patient over the next certification period. Dr. A is the neurologist. Patient reports improvement with burning and frequency, but still present. Found inside – Page 51Sample SOAP Note The documentation example included is for a 30-year-old female patient who is seeking care for fatigue. Note that the plan of care is ... The plan is to reconnect the bowel back next month. All Rights Reserved | This website is a property of Pear Solutions, LLC located at 539 W. Commerce St #3412 Dallas, TX 75208 . Other significant health history includes significant risk for fall with the caregiver reporting a serious fall in May 2009 and sustaining a head injury and resulting concussion. Patient education documentation should include information about the learner’s reactions and feelings as well as responses to open-ended questions. Patient’s blood pressure is controlled moderately, but needs a close watch, as some systolic readings have been in high 150s and touching 160. Patient reports continence with bowel and bladder.