Heart transplant patient teaching documentation

Appropriate documentation of pre- and post-heart transplantation patient teaching has become increasingly challenging for the clinical nurse specialist (CNS) due to an increase in volume of referrals for heart transplantation evaluation, co-morbidities of those seeking transplant, complexity of the information that must be provided to candidates, demands by the Joint Commission on Accreditation of Health Care Organizations, and the compressed time for teaching, especially in the post-transplant hospitalization period. No heart transplant patient teaching documentation format was found in the literature that assisted us in overcoming these new demands. Using a center-developed Pre- and Post-Heart Transplant Patient Teaching Record, we describe a hypothetical case study to illustrate successful documentation by the CNS and the transplant team of the patient teaching plan of care.