Instructions Are Written for the Kitchen Table
I studied nutrition before I studied public health, and one of the first things nutrition training teaches is that a meal plan is never followed in the office where it was written. It is followed, or set aside, at a kitchen table on a weeknight with children in the room. Patient instructions work the same way. Whether the sheet was accurate when the clinician handed it over matters less than whether it still makes sense the next morning, when the patient is alone with it and the details of the appointment have started to fade.
Most patient instruction sheets are accurate. Many are also crowded. They use unfamiliar terms, list three phone numbers without saying which one to call for what, and include a phrase such as “follow up as directed,” which is meaningful to staff and tells the reader very little.
Write for the moment it will be read
It helps to ask when and where the person will actually read the document. At the front desk, they are trying to schedule something. At home, they are trying to prepare for a test or understand a medication. Those are different tasks and they call for different opening lines.
I recommend putting the action first. If the next step is scheduling, say who will call whom, by what date, and what to have on hand. If the next step is to wait for a call, say what to do if the call does not come. That last point deserves more attention than it usually gets. A common way a care plan breaks down is that the patient hears nothing, and few instruction sheets prepare them for that.
I then check the sheet against four questions the reader is likely to have:
- What happens next?
- When will it happen?
- Who is responsible for the next contact, the patient or the clinic?
- What should I do if it does not happen?
When a document cannot answer the fourth question, the cause is usually not the writing. More often the organization has not decided what the answer is. Editing will not repair the pathway, but it does bring the gap to light, and that is useful in itself.
Test it with readers
Clinicians evaluate instructions for accuracy. Readers evaluate them by whether they can find the one thing they need. A simple test is to hand the sheet to a few patients or community advisors, ask them to locate a specific answer, and watch where they hesitate. It is also worth asking which step they would take first and what they would do if that step did not work.
AHRQ includes the teach-back method in its health literacy toolkit for a similar reason. The patient is asked to describe the plan in their own words, and if the description is off, the explanation is what needs to change. I apply the same standard to written material. If three readers interpret a sentence three different ways, the sentence should be rewritten.
Translation adds one more consideration. A translated sheet that keeps the same crowding and the same “as directed” language is no easier to use than the original. The reader has the same difficulty in a second language. It works better to simplify the source document first and translate it afterward.
Give each document an owner
Instruction sheets go out of date quietly. Office hours change, the phone tree is reorganized, an eligibility rule is revised, and the sheet continues to direct people to a number that now rings somewhere else. Every frequently used document should have a person responsible for it, a scheduled review date, and a way for front-line staff to report that the wording no longer matches what actually happens.
I would also caution against judging a sheet by its reading level alone. Repeat calls asking for clarification, missed next steps, and partially completed forms are better indicators of whether the instructions worked at the kitchen table, which is where they were always going to be used.
Sources
About the author
Sherry Sayari, MPH, is an Operational Standards Evaluator who has led population health, community outreach, and social services programs. More on the About page.
