Written: August, 1989 Nursing Policy: E-05 Reviewed: 9/90 LSUHSC-Shreveport, LA Revised: 9/91; 8/92; 12/94; 2/95; 10/97;

8/99; 7/01; 7/04; 10/06; 2/09; 8/09; 5/12

PATIENT/FAMILY EDUCATION PURPOSE: To promptly identify patient/family/significant other educational needs and to provide for specialized nursing patient education to meet those needs during the hospital stay. To provide a mechanism for nursing documentation regarding patient/family education of pre-and post-surgical diagnostic procedures. DEFINITIONS: 24 Hour NursesNote- the tool, paper or electronic, that the registered nurse and those whom they delegate to, documents the care of the patient for each 24 hour period, beginning daily at the beginning of the am shift. POLICY: 1. All patients and their co-learners, shall be assessed upon admission by a nurse and educational needs identified. This initial assessment shall include any religious/spiritual, financial, cultural, literacy, language, cognitive, sensory (vision/hearing) and other barriers to education and shall be documented in the 24-Hour Nurses Notes, Patient Education Section. Once educational needs are identified, the registered nurse shall determine if interventions to meet these needs shall be provided by: a. b. Unit Nursing Staff Specialized nursing educators such as Diabetes Educators and Wound, Ostomy, Continence Nurses (See Nursing Policy, D-10: Diabetes Educator and E-15, Wound, Ostomy, Continence Nurse). http://www.sh.lsuhsc.edu/policies/policy_manuals_via_ms_word/Nursing/D-10.pdf http://www.sh.lsuhsc.edu/policies/policy_manuals_via_ms_word/Nursing/W-30.pdf Collaboration with other department/disciplines. When necessary, the need for physician's orders shall be communicated to the patient's physician.

2.

c.

3.

Patient educational activities as well as response to those interventions performed by the nursing staff shall be documented in the. Patient Education section of the 24-Hour Nurses Notes shall be used to document education activities. However, it is not intended to replace specialized forms not available in the electronic format. All patient education materials shall be patient centered at a level the patient can understand. Nurses may use the Nursing Consult database to obtain up-to-date teaching information. E5-1

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4.

Patient/Family education regarding surgical/diagnostic procedures is vital to a patient's care and well-being. The teaching process shall be documented in the patient's medical record. Upon discharge, a completed After Visit Summary (AVS) will be issued to the patient. Instructions regarding follow-up appointments, diet, exercise, activity, equipment, medications, medical equipment and other special instructions shall be documented and signed by the patient in the space provided on the form. A copy stays with the paper medical record (Lite Chart) and the patient receives an identical copy. For additional information, see Hospital Policies; 5.1.0 - Hospital Patient/Family Education Policy, and 5.1.2 - Patient Education Regarding Potential Food/Drug Interactions, 8.21.0 Medication Reconciliation. http://www.sh.lsuhsc.edu/policies/policy_manuals_via_ms_word/hospital_policy/h_5.1.0.pdf http://www.sh.lsuhsc.edu/policies/policy_manuals_via_ms_word/hospital_policy/h_5.1.2.pdf http://www.sh.lsuhsc.edu/policies/policy_manuals_via_ms_word/hospital_policy/h_8.21.0.pd f

5.

6.

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RESPONSIBLE PARTY RN, RN Applicant RN, RN Applicant, LPN

ACTION 1. Identifies educational needs and documents those needs in the plan of care, updating and revising as needed. Initiates plan for patient education within 8 hours of admission documenting any religious, cultural, literacy, language, cognitive, sensory and/or other barriers to education in the space provided. Delegates nursing educational activities to appropriate nursing personnel. Collaborates with other disciplines, as indicated by patient assessment. Initiates appropriate consults to specialized nursing educators. Teaches patient/significant other and documents education activities, interventions and in the Nurses Notes, or an approved special teaching form. Performs and documents preop-family response/level of understanding on pretest teaching and patient/family response/level of understanding in the 24-Hour Nurses Notes, Patient Education section. Notes any patient/significant other instructions, as well as referrals and action taken to meet identified needs post discharge on the AVS as applicable: a. Number to call for questions b. Date of Discharge c. Follow-up appointments and contact number for that unit d. Diet e. Activity f. Medical equipment/supplies g. Medications/Prescriptions h. Smoking Cessation assistance, as appropriate CHF written instructions as appropriate i. Post transfusion precautions j. Other special instructions Signs Discharge Instructions/AVS

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3. 4. 5. 6.

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8.

Patient/Family RN, RN Applicant, LPN

9.

10. Places Discharge Instructions in Lite Chart and gives the patient a Copy.

References: E5 - 3

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Hospital Policy 5.1.0 Hospital Patient and Family Education http://www.sh.lsuhsc.edu/policies/policy_manuals_via_ms_word/hospital_policy/h_5.1.0.pdf Hospital Policy 5.1.2 Patient Education Regarding Potential Food/Drug Interactions http://www.sh.lsuhsc.edu/policies/policy_manuals_via_ms_word/hospital_policy/h_5.1.2.pdf Hospital Policy 8.21.0 Medication Reconciliation

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_______________________________________ Renee Lamb, RN Administrative Nursing Director of Medicine Services

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_______________________________________ _______________ Jean DiGrazia, MBA, RN Date Assistant Hospital Administrator for Patient Care Services

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