Be sure to document hygiene education. You routinely teach patients about their options for pain control. Make sure you have documented this education for any patient who may be experiencing pain. Auditors may question patients about pain, and follow-up by looking for education documentation within the chart. Documentation serves as the tool to facilitate this communication.
Documentation is the KEY for showing compliance.
An institution can get into trouble if documentation about education is spotty, or is scattered throughout the chart and difficult for an auditor to locate. If you were to rely on documenting education in your progress notes, you'd have to remember to include these elements within each note. The goal was to develop a user-friendly documentation system that would be utilized universally in all areas and disciplines within the system. A specific location would then be designated within the medical record, so that everyone would be able to access and communicate education information. By documenting on this tool, you do NOT have to narrate all of the items that would otherwise be required to meet the patient education standards in your progress note.