Accurate documentation of client health teaching is a critical compone

QUESTION

Accurate documentation of client health teaching is a critical component of quality care. When documenting in the client’s chart about health teaching for a client admitted for alcoholism, the nurse should write

a. “Client was educated on the physical complications of alcoholism.”
b. “Client received written and verbal instructions on diet and vitamin therapy.”
c. “Client was educated on the signs and symptoms of alcohol withdrawal and when to seek medical assistance.”
d. “Client was able to identify five triggers for relapse and was assisted to develop a relapse prevention plan.”

ANSWER:

ANS: D
The Joint Commission requires written documentation of all client health teaching. Notes about the initial assessment should be succinct, but comprehensive and objective. Teaching content should be linked to assessment data, including client preferences, previous knowledge, and values. Included in the documentation are the teaching actions, the client response, and any clinical issues or barriers to compliance. If family members are involved, you should identify their role, content provided, and teaching outcomes in your documentation. Accurate documentation helps ensure continuity and prevents duplication of teaching efforts. The client’s record informs other health care providers of what has been taught and what areas need further work.