A potential limitation to using written materials as part of patient education is the patients level

Tracking the changes and deletions of written materials over time

Check the date, file twice, and purge old copies

Written materials are a key component of the teaching process. They provide a way for patients and family members to take home the information from lessons taught verbally by a clinician.

These teaching sheets and pamphlets can reinforce the verbal discussion that has taken place, explains Diane Moyer, BSN, MS, RN, program manager for consumer health education at The Ohio State University Medical Center in Columbus.

In addition, these materials can act as a reminder of the different points to cover when a clinician does not regularly teach about a diagnosis or procedure, she says.

Although an important educational tool, written materials can also provide factual information on what patients were taught at any point in time. This is important when there is a possible lawsuit against a medical institution.

A year or so ago Moyer was contacted by the legal department at The Ohio State University Medical Center to provide a copy of a handout from a certain date so the legal team would know what instructions were being provided to the patient at that time.

"It was documented in the record the patient had been given a particular handout but the handout had been updated several times since then and they weren't sure exactly what had been given to the patient so we were able to go back and pull that out," says Moyer.

Because it is important to pinpoint lessons taught on any particular date, there must be a tracking system in place so written materials can be traced over time, whether they have been discontinued or the content changed.

At The Children's Hospital of Philadelphia policy requires written materials be kept for 21 years according to the statute of limitations on pediatric cases.

"You can get a call from legal asking ‘What were we teaching about tracheotomy care in 1977?' and you need to be able to produce it," says Linda S. Kocent, RN, MSN, coordinator of patient-family education at The Children's Hospital of Philadelphia.

Kocent says every document created for patient education is given a cover sheet and stored for 21 years. The cover sheet has the title of the document, the date it was created, patient demographics, the names of the reviewers, what benchmarking was done, what the best practices were, what pieces of literature were used to back the information in the pamphlet, the readability level, and the clinical experts that signed off on the material.

The material is stored in several cabinets. However, it also is backed up electronically on CDs without the cover sheet and can be retrieved according to its date, says Kocent.

Twenty-one years is also the policy at The University of Washington Medical Center. "If materials are deemed obsolete or become revised we hang on to the earlier version in a hard copy file and within the last few years we keep them on electronic files as well," says Laura Seuferling, MPH, a health educator in patient and family education at The University of Washington Medical Center in Seattle.

However, only the materials written in-house can be kept in an electronic file. Therefore hard copies of handouts purchased from vendors or medical organizations are archived.

While there is a file cabinet of outdated written materials at The Ohio State University Medical Center, in recent years a technical auditor has stored the entire inventory on disk. Every quarter the inventory is saved on disk so any document can be pulled up within a time frame to review what was being taught.

"We would basically have all the changes made to those documents through that time frame," says Moyer.

The auditor has a separate tracking tool for discontinued written material that identifies the date it was removed from inventory.

When a new document is placed on the medical center's Intranet or updated, the date at the end of the manuscript is changed so it is easy to determine when the last revision took place, says Moyer.

For some conditions, such as heart failure and diabetes, notebooks have been created at The Ohio State University Medical Center. When changes are required within these documents they are made the next time the books are printed, says Moyer.

Remove from circulation

Once a pamphlet or teaching sheet has been discontinued it is important to ensure that staff members are not still handing it out to patients. Also when changes are made to documents staff must be notified so they will get rid of any copies they may have filed.

Staff members at Ohio State are notified of the changes through an internal newsletter and also the changes are documented in the minutes of the meetings held by the patient education committee for others to read, says Moyer.

Other safeguards are in place to prevent outdated materials from being distributed.

"We really encourage people to use the materials off the Intranet so they are always getting the most current copy. If we have areas that make multiple copies we encourage them very strongly to not make a copy from the last one that is in the file but to go back to the web site and pull the most resent so they are sure they are copying the most current document," says Moyer.

Staff members at The Children's Hospital of Philadelphia are asked to print only a single copy from the Intranet and if they use the document frequently and want to stock it on the unit they must order it from the forms vender under contract with the hospital, says Kocent. In that way it will be less likely material that has been changed or discontinued will be handed out to patients and family.

Often staff know that written material has been updated for they are the ones that ask for the changes. There are many reasons why they would notify the patient education department that a handout needs revision.

If there were a practice change the patient education department would be notified. Also, a particular way of doing something might not be best practice anymore.

"We monitor usage of documents and maybe it is a low use item. Then you have to investigate why it isn't being used. It may be because it is poorly written or outdated," says Kocent.

If the monthly report from the forms vender, where patient education documents are stored, indicates that a particular teaching material is not being used then a decision is made on whether to discontinue it or revise it.

In-house educational materials in the database at the University of Washington Medical Center are routinely reviewed every three years. To make the project manageable the database is divided into thirds, therefore each year a third of the written materials is sent for review to the department that created them. However in between the review period staff are to notify the patient education department when changes are needed, says Seuferling.

Another way outdated materials are identified is through audits. The practice was started before a survey by the Oakbrook Terrace, IL, based Joint Commission on Accreditation of Healthcare Organizations. At that time, staff from the patient education department went to each department to see what was in their file cabinets and found some had up-to-date materials and others were using older handouts. Now those audits are done routinely.

"Some departments have a designated patient education person who is continually updating and keeping things current, and other departments don't have a designated person so the job falls on the shoulders of the manager. Sometimes it slips through the cracks so we try to support them by doing an audit," explains Seuferling.

Materials purchased from a commercial vender should be re-ordered on a regular basis to help ensure they are up to date, says Moyer. At The Ohio State University Medical Center commercial materials are mainly used in the cancer center and in the consumer health library. Before materials are purchased a patient education representative with expertise in that particular area reviews the material.

Encourage tracking of use

Although patient education managers work hard to make sure written materials are up to date and outdated materials are archived within a system that tracks their changes and the date they were removed from circulation, it is also important for clinicians to track their use when teaching patients.

To make documentation easier, teaching flow sheets at The Ohio State University Medical Center have a list of written materials at the end that can be checked when handed to a patient.

"Whether or not the materials are handed to patients we can only track based on what the staff have documented," says Moyer.

The use of a patient and family education flow sheet is required in all inpatient areas at The Children's Hospital of Philadelphia. All information given to patients is supposed to be documented on the form whether verbal instruction, audio/visual instruction or a written piece, says Kocent.

In outpatient areas the education flow sheet is an option because educational information is often included on the visit sheets.

Problems can occur when clinicians pull material from an Internet web site and there is no record of the information.

Therefore the policy at The Children's Hospital of Philadelphia is to refer families only to web sites rather than provide copies of information from one of them. Kocent says some departments have lists of web sites they give to families along with other written materials and others simple write the address for the web site on a piece of paper.

"If you refer them to the web site it is like referring them to the library. You are simply saying, ‘Go here and look this up.' It is not something you are prescribing or saying we endorse, it is saying to get more information you might find this helpful," explains Kocent.

At Ohio State clinicians are encouraged to use written material from the Intranet and only use an Internet web site if it is linked to the internal web system. These sites have been reviewed by staff and closely mirror what is taught within the medical center.

However documentation of the materials handed to patients is important whether pulled from the Intranet or Internet.

"If we knew where it came from we could potentially go back to that organization or group and find out if they still have a copy of the document they had on their web site at a particular time," says Moyer.

Sources

For more information about tracking written materials, contact:

• Linda S. Kocent, RN, MSN, coordinator of patient-family education, The Children's Hospital of Philadelphia, 34th Street and Civic Center Blvd., Philadelphia, PA 19104. Phone: (215) 590-3661. E-mail: [email protected].
• Diane Moyer, BSN, MS, RN, program manager, consumer health education, The Ohio State University Medical Center, 1375 Perry Street Rm 524, Columbus, Ohio 43201. Phone: (614) 293-3191. E-mail: [email protected].
• Laura Seuferling, MPH, health educator, patient and family education, University of Washington Medical Center, 1959 NE Pacific St., Box 358126, Seattle, WA 98195. Phone: (206) 598-3473. E-mail: [email protected].

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