Supreme Court Justice Potter Stewart famously said he could not define hard-core pornography, but “I know it when I see it.”

We in health care seem to have the same reaction to the phrase, verbalizes understanding when it comes to patient education.  Patient medical records, including electronic medical records now include free text notes or check boxes indicating the patient verbalized understanding without actually defining this phrase.

In a world where ambiguous and undefined terms are avoided, verbalizes understanding pops up as boilerplate language, and no one questions what it actually means. Without a definition, we cannot be sure of accurate documentation, nor can we use that part of the medical record to improve patient education.  In nursing, allied health, and medical literature verbalizes (or verbalize or voices) understanding appears as though all health care practitioners march along in lock-step, everyone in agreement on what it means.  That is not the case.

The Joint Commission, with standards that often determine the language of the policies of health care facilities, does not have a formal definition for verbalizes understanding.

In a recent informal conversation with nurse and health sciences librarian colleagues, I found a variety of points of view.  Some claimed there is no difference between the terms verbal and oral.  Some stated that verbalizes is the equivalent of voices. Some were unaware that verbalize means using words, not solely the spoken word.  Some said that the idea of teach-back to assess learning is part of their own working definitions of verbalizes understanding.

Go to your favorite medical or nursing dictionary and you will find verbalizes understanding is defined as … well, it isn’t there.

A search of MeSH terms on the National Library of Medicine site suggests you try using the term comprehension.

So what’s the big deal?

The big deal is this: health care records need to use words and terms with clear and agreed-upon definitions. When health care records use defined and understood terms, data gleaned from them are useful and reliable.  Hospitals and providers interested in patient education can use the reliable data to discover what they are doing well and what they need to improve.

Health care researchers and quality assurance teams often use retrospective medical record reviews to analyze some aspect of care.  A patient education retrospective record review can answer the questions, “How well are we doing patient education?”  “What did the patient learn?” but only if the records contain reliable data.

“Patient (or family or caregiver) verbalizes understanding” could mean:

• The patient spoke, saying, “I understand.”
• The patient nodded his head, wrote, signed, or placed his signature on a piece of paper indicating he understands.
• The patient, with or without using words, performed a procedure such as drawing up a correct dose of insulin.
• The patient, using words—spoken, written or signed–described how he would perform a procedure such as drawing up a correct dose of insulin.
• The patient, with or without using words, performed a procedure (such as drawing up a correct dose of insulin) and did so correctly and reliably.
• The patient, using words—spoken, written, or signed–described how he would perform a procedure (such as drawing up a correct dose of insulin) and did so correctly and reliably.

With such a range of possibilities, how do we know what accurately describes the situation?

A medical record employing the ambiguous phrase patient verbalizes understanding, with no definition, is not a reliable rendering of the patient education experience.  It cannot be used to improve patient education care or systems.  It may create a barrier of assumptions for colleagues following the patient’s transition from hospital to home.  Further, inadvertently inaccurate documentation may place the practitioner in an uncertain ethical and legal situation.

The thin edge of a wedge?

Verbalizes understanding is entrenched in health care documentation.  Arriving at a common definition makes more sense than arriving at a new phrase.

A definition should answer the questions:

• What does verbalize mean in this context?
• What is the difference between verbalizes and voices?
• What does understanding mean in this context?
• Is this phrase adequate to document an assessment of learning?

Is defining this key phrase the thin edge of a wedge to a larger responsibility?  Is this just the start of defining other patient education terminology? Should patient education specialists be developing their own taxonomy?

The world of patient education has changed rapidly in the past two decades while it’s infrastructure of common terms and definitions scrambles to keep up.  Clear and accurate documentation is required to improve how patient education occurs. A definition for the commonly used but ambiguous phrase, verbalizes understanding is needed. A patient education taxonomy could also provide us with the structure and common language needed to study and promote this essential component of ethical, high quality patient care.

Susan C. Shelly has worked in both academic and hospital libraries, with an emphasis on patient education and health literacy.