“Patient educated, verbalizes understanding.” What a court asks about teaching you only named

On the stand · 10 of 12

Patient educated, verbalizes understanding.

Educated on what, and what did the patient say back? The phrase records that you taught. It does not show what you covered or what the patient could explain or do. Years later, when nobody remembers the patient, it is all the chart has.

What they ask about it

The triage nurse's testimony, as the appeals court summarized it
Varas testified that a patient's signature on the discharge instructions usually verifies that the nurse saw the patient again and that the patient understood what had been explained.
Source: Almonte v Shaukat, 2022 NY Slip Op 02221 (App Div 1st Dept), 2022
A federal appeals court, on records saying the patients verbalized understanding
The district court relied on medical records indicating that hospital staff were able to ascertain Plaintiffs’ primary symptoms, and that Plaintiffs verbalized understanding of treatment and discharge instructions. We reject this standard for two reasons.
Source: Silva v. Baptist Health South Florida, Inc., 856 F.3d 824 (11th Cir. 2017), 2017
A legal nurse consultant who works with attorneys (Nurse.com)
Another vague statement is, "Patient educated, verbalizes understanding." If a nurse is teaching a patient how to use a nebulizer, for example, they should document details about what was taught -- such as how to use the correct dosage, frequency of use, and potential side effects -- and information about a scheduled follow-up appointment with the patient's physician to monitor progress.
Source: Nurse.com: Protect Yourself From Nursing Lawsuits, Other Legal Issues (legal nurse consultant Janice Dolnick, BSN, RN)
A malpractice insurer's documentation guidance (NSO)
Include patient communication. Document patient education regarding treatment and any educational materials, resources, or references provided to the patient. Patient complaints, questions, and other concerns should also be documented, as well as all steps taken to resolve their concerns.
Source: NSO: Fundamental charting principles for nurses (Defensive Documentation: Steps Nurses Can Take to Improve Their Charting and Reduce Their Liability)

It happened in court

Almonte v Shaukat

Appellate Division, First Department (New York) · 2022

The chart recorded a recommendation to follow up for an ultrasound and mammogram, but the discharge form she signed did not contain that plan. Neither the triage nurse nor the physician assistant remembered her, and she denied seeing the nurse again after triage. The appeals court unanimously reversed the dismissal of the case: what, if anything, she was told at discharge was a disputed fact.

Although defendants produced a signed discharge instruction form, the form does not contain the treatment plan that is otherwise set out in plaintiff's chart. The signed form makes reference to a breast cyst and provides a follow-up location for a breast clinic without further instruction. Neither Varas nor Rogan had an independent recollection of their examination or treatment of plaintiff, and plaintiff denied seeing Varas again after the triage.

Silva v. Baptist Health South Florida, Inc.

U.S. Court of Appeals for the Eleventh Circuit · 2017

Deaf patients sued two hospitals under the ADA and the Rehabilitation Act, saying they could not communicate effectively with hospital staff. The lower court relied on records saying they verbalized understanding of treatment and discharge instructions. The appeals court said a charted “verbalized understanding” at most showed the point was disputed, and a disputed material fact goes to a jury. It reversed and remanded.

Further, as we have explained, evidence that the medical staff could ascertain a patient’s basic symptoms and convey treatment instructions is not enough for us to conclude, as a matter of law, that a disabled patient’s level of informational exchange was equal to that of non-disabled patients as required by the ADA and RA.

Write instead

Reviewed 3 new meds (metoprolol, furosemide, KCl). Teach-back: pt named each med, its purpose and dose, and stated she will hold metoprolol and call if HR under 55.

Documenting discharge teaching so the chart shows the patient understood

Already charted it this way?

Do not change the original entry. Not for any reason, and not after you hear there is a claim.
Never alter a patient’s record - that is a criminal offense
Source: NSO: Do's and Don'ts of Documentation
Every change shows. The record keeps the time of each entry and each deletion.
Correct your charting errors in accordance with your organization’s policies and procedures, ensuring that it is clearly marked as a late entry. Remember: electronic healthcare records automatically date and time each entry and identify electronic deletions, so any attempt to alter the patient healthcare information record is discoverable.
Source: NSO, Defensive Documentation: Steps Nurses Can Take to Improve Their Charting and Reduce Their Liability
Add a late entry, the way your policy says. Mark it as late. Write only what you actually remember.
If something needs to be added to documentation, always chart that information with a notation that it is a late entry and include the time and date
Source: NSO: Do's and Don'ts of Documentation
Use the time you are writing it. Name the time of the event inside the entry; the entry itself carries today's time.
Enter the current date and time – do not attempt to give the appearance that the entry was made on a previous date or an earlier time.
Source: ACDIS Q&A: Policies for late entry documentation
Not to protect yourself. A note added after an incident to cover the gap reads as guilt.
Don’t chart defensively after an incident has occurred. This is a red flag to lawyers later on. Defensive charting is not necessarily going to stand up in court as actual evidence of negligence, but it does telegraph the message that you believe you were at fault, and that’s the red flag the lawyers will be looking for.
Source: The Health Law Firm, 25 Legal Dos and Don'ts of Nursing Documentation
Got a subpoena or a deposition notice? Call your liability insurer and your risk manager before anything else.
The first action nursing professionals should take is to inform their professional liability insurance provider and employer’s risk manager or legal counsel of the deposition notice.
Source: CNA and NSO: Nurse Spotlight, Preparing for a Deposition
The hospital's lawyer is not your lawyer. They represent your employer.
Keep in mind that this attorney is not your attorney, but is your employer’s attorney; therefore, you may wish to retain a board certified healthcare attorney or a litigation attorney to be “on your side” for the deposition.
Source: The Health Law Firm: Preparing for a deposition, for nurses
At the deposition, do not guess. Answer what you saw and what you know. Not remembering is an answer.
7. If you do not know the answer to a question, do not guess. Say that you do not know the answer. 8. If you do not remember something, say so.
Source: CNA and NSO: Nurse Spotlight, Preparing for a Deposition
You can describe your routine. What you always do is evidence too, but it is weaker than the note.
You can speak about your custom and practice in general at deposition, but there is no substitute for a well-written note and initialed treatment boxes.
Source: I Advance Senior Care, Nursing depositions: Duty or disaster?

Not legal advice. Your facility policy, your state and your own attorney are what bind you. Every question and every quote here links to where it was published; read the source, not us. Written by a med-surg RN, ten years, day shift. Why there is no name on it.