By Miranda Niemas, Nursing Student (BSN candidate)

This guide is currently pending review by a licensed registered nurse.

Last updated: October 13, 2026

Patient Education and Nursing Notes Documentation: The Complete Guide

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Your patient asked about her new medication, and you explained it. After answering her questions, she nodded, and you moved on to your next task. Now what do you write? "Patient educated on medications" sounds weak - because it is. That note tells the next nurse nothing: which medication? What did you say? Did she actually understand? Could she repeat it back? Were there barriers? A surveyor reading that note finds no evidence that education occurred. During my med-surg rotation, I watched a preceptor spend 20 minutes teaching a patient about insulin self-injection, yet the documentation consisted of just one sentence. The teaching was excellent, but the documentation was invisible.

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Why This Matters

Regulatory bodies: The Joint Commission (PC.02.03.01), Centers for Medicare & Medicaid Services (CMS §482.43), State Boards of Nursing

Patient education ranks among the most frequently performed nursing activities, yet it often suffers from poor documentation. Joint Commission standard PC.02.03.01 requires nurses to document patient education in a manner that reflects the patient's abilities, readiness, and preferences. CMS §482.43 mandates discharge planning that includes education for patients and their families. State boards of nursing recognize patient education as a core component of the nursing process. Despite these requirements, studies consistently reveal that education documentation remains vague, incomplete, or entirely missing. The gap between what nurses teach and what appears in the chart is substantial. This gap poses a liability: if documentation is lacking, regulators and attorneys will treat the education as if it never occurred. The Schillinger et al. study (2003) demonstrated that patients whose physicians employed the teach-back method achieved significantly better glycemic control. If this method proves effective, it must be documented in the chart.
  1. Joint Commission PC.02.03.01 - Patient Education Standards — The Joint Commission (2025)
  2. AHRQ Health Literacy Universal Precautions Toolkit - Teach-Back Method — Agency for Healthcare Research and Quality (AHRQ) (2020)
  3. CMS §482.43 Condition of Participation: Discharge Planning — Code of Federal Regulations, Title 42 (2024)
  4. Closing the Loop: Physician Communication With Diabetic Patients Who Have Low Health Literacy — Schillinger D, Piette J, Grumbach K, et al. Arch Intern Med. 2003;163(1):83-90 (2003)

Types of Notes Covered on This Page

This guide addresses three related documentation areas that often intertwine: patient education documentation, discharge teaching documentation, and narrative nursing notes. Patient education documentation records any teaching event during the hospital stay, including medication education, disease process instruction, wound care demonstrations, dietary counseling, and activity restrictions. Discharge teaching documentation represents a specific subset of patient education, covering everything the patient needs to know before going home: medications, follow-up appointments, warning signs, activity restrictions, dietary modifications, wound care, equipment use, and who to contact with questions. Narrative nursing notes consist of free-text clinical notes that capture events, observations, and clinical reasoning that do not fit neatly into structured charting fields. These three documentation types overlap in practice; for instance, you might write a narrative note about a discharge teaching session that included medication education. Understanding the purpose of each type helps you place the right information in the appropriate context.

The 5 Elements of a Patient Education Event

Whenever you teach a patient something, document all 5 elements. Missing even one creates a gap that a surveyor or attorney can question.

Topic Taught

Be specific. "Medications" is not a topic - "metformin 500mg BID: purpose, timing, side effects, and when to hold" is a topic. "Diet" is not a topic - "1800-calorie diabetic diet: carbohydrate counting, meal spacing, and reading nutrition labels" is a topic. The more specific your topic, the stronger your documentation. If you taught multiple topics in one session, document each one separately with its own response and teach-back. Bundling everything into "patient educated on discharge instructions" erases the detail that proves the education happened.

Method Used

How did you deliver the education? Options include verbal explanation, written handout, video, demonstration, return demonstration, or a combination. The method matters because it affects learning; for example, a verbal explanation of insulin injection technique differs from a demonstration with return demonstration. Document the specific method for each topic. If you used printed materials, note the title or source: "ADA handout: Managing Your Blood Sugar provided." If you demonstrated a skill and the patient performed a return demonstration, document both steps separately.

Patient Response

Document what you observed, not what you assumed. "Patient verbalized understanding" is better than "patient understood" because you can observe someone verbalizing, but you cannot directly observe understanding. Stronger responses include: "Patient correctly stated the three signs of hypoglycemia," "Patient demonstrated proper injection technique in the right thigh," and "Patient asked a clarifying question about the timing of the evening dose." Also document negative responses: "Patient appeared distracted during teaching, checking phone repeatedly," "Patient stated 'I already know all this' and declined further education," and "Patient became tearful when discussing diagnosis." The response informs the next nurse whether the education was effective.

Teach-Back Verification

Teach-back serves as the gold standard for verifying patient understanding. Ask the patient to explain what you taught them in their own words or demonstrate the skill back to you. Avoid asking, "Do you understand?" (patients almost always say yes). Instead, ask, "I want to ensure I explained this clearly - can you tell me in your own words when you would hold your metformin?" Document the patient's actual teach-back response: "Patient stated: 'I hold the metformin if I'm not eating or if I'm going for a test where I can't eat.'" That direct quote provides powerful documentation. If teach-back was unsuccessful, document that as well; it shows you assessed understanding and identified a learning gap. For example, "Patient unable to state signs of hypoglycemia after initial teaching. Education reinforced with written handout. Repeat teach-back: patient correctly identified 3 of 4 signs."

Barriers to Learning

Barriers include language differences, low health literacy, cognitive impairment, hearing or vision deficits, pain, fatigue, emotional distress, cultural considerations, and lack of motivation. Document barriers even when none exist: "No barriers to learning identified" constitutes a complete assessment. When barriers are present, document both the barrier and your accommodation: "Primary language Spanish; education provided in Spanish via certified interpreter (ID #4472). Written materials provided in Spanish." "Patient reports 4th-grade reading level; education provided verbally with pictorial handouts." "Patient experiencing pain 7/10; pain managed with hydrocodone 5mg PO at 1400, education resumed at 1500 when patient reported pain 3/10." Documenting barriers and accommodations demonstrates that you individualized the education plan, which aligns with Joint Commission PC.02.03.01 requirements.

Discharge Teaching Documentation

Discharge teaching represents the highest-stakes patient education I will document. CMS §482.43 mandates it, the Joint Commission surveys it, and readmission rates directly correlate with it. A complete discharge teaching session covers a checklist of topics, each requiring the same five elements as any educational event. The standard discharge teaching checklist includes: (1) Diagnosis and disease process - what happened and why. (2) Medications - name, dose, route, frequency, purpose, side effects, interactions, and when to hold for every discharge medication. (3) Follow-up appointments - who, when, where, and what to bring. (4) Activity restrictions - what the patient can and cannot do, and for how long. (5) Dietary modifications - any dietary changes, fluid restrictions, or nutritional guidance. (6) Wound care - if applicable: how to change dressings, signs of infection, when to call. (7) Warning signs - specific symptoms that require calling the provider or returning to the ED. (8) When to call the doctor - distinct from warning signs; includes routine questions, refill needs, and non-urgent concerns. (9) Equipment and supplies - DME setup, supply ordering, troubleshooting. (10) Emergency contacts - provider office, nurse line, pharmacy, 911 criteria. Missing a topic creates a gap. Document each topic with the five elements. If a topic does not apply (no wound, no equipment), document that I assessed it and found it not applicable - "Wound care: N/A, no wounds." This proves I reviewed the topic and made a clinical judgment, rather than forgetting it.

The Teach-Back Method

Teach-back is the most evidence-supported technique for verifying patient understanding. The Schillinger study demonstrated its effectiveness; now you need to document its use.

The Evidence Behind Teach-Back

Schillinger et al. (2003) studied 408 patients with type 2 diabetes and found that patients whose physicians assessed recall using teach-back achieved significantly better glycemic control (HbA1c) than those whose physicians did not. This effect was particularly strong for patients with low health literacy. The AHRQ adopted teach-back as a core component of its Health Literacy Universal Precautions Toolkit. The method is now standard practice across nursing, medicine, and patient education. The evidence is clear: asking "Do you understand?" fails to ensure comprehension, as patients often say yes regardless of their understanding. Teach-back identifies misunderstandings before patients leave the office with them.

How to Use Teach-Back

The technique has three steps. First, teach the information using plain language (avoid medical jargon unless you define it). Second, ask the patient to explain it back: "I want to make sure I did a good job explaining this. Can you tell me in your own words what you will do if your blood sugar drops below 70?" Frame it as checking YOUR explanation, not testing the patient - this reduces anxiety and defensiveness. Third, assess the response. If accurate, reinforce and move on. If inaccurate or incomplete, re-teach the specific gap (not the entire topic), then ask for teach-back again. Repeat until the patient can accurately restate the information. For skill-based education (injections, wound care, inhaler technique), teach-back becomes return demonstration: the patient performs the skill while you observe and correct.

Documenting Teach-Back

Your documentation should include: (1) that you used teach-back, (2) what the patient said or did, and (3) whether it was accurate. A strong example: "Teach-back performed. Patient asked to explain when to call the doctor. Patient stated: 'If my incision gets red or starts draining pus, or if I get a fever over 101, I call the surgeon's office. If I can't breathe or have chest pain, I call 911.' Teach-back accurate - patient correctly identified wound infection signs and emergency criteria." If teach-back was not accurate on the first attempt: "Initial teach-back: patient stated 'I take the blood thinner with food.' Incorrect - warfarin can be taken with or without food but must be taken at the same time daily. Re-educated on timing consistency. Repeat teach-back: patient stated 'I take it at 6 PM every night; it doesn't matter if I ate.' Teach-back accurate on second attempt."

Narrative Nursing Notes (When and How)

Narrative notes serve as the free-text section of your chart, capturing events and clinical reasoning that structured fields cannot accommodate. Unfortunately, they are often misused.

When to Write a Narrative Note

Write a narrative note when an event occurs that structured fields cannot capture. This includes changes in patient condition requiring clinical context, patient or family interactions needing documentation (such as treatment refusals, complaints, or emotional events), communication with providers that involves clinical reasoning, incidents or near-misses, complex clinical situations where your assessment and reasoning must be visible, or when you need to document the "story" behind a set of data points. For example: "Patient found on floor at 0345. Fall assessment completed - see Morse Fall Scale. Narrative: Patient states he was attempting to reach the bathroom without calling for assistance. Denies head strike, denies LOC. Neuro checks initiated per protocol. MD notified at 0350, orders received for..." The narrative captures the context that structured fields cannot convey.

How to Format a Narrative Note

Use a consistent structure for your notes. Time-stamp every entry. State the facts first, followed by your assessment and the action taken. Avoid editorializing; for instance, instead of saying "patient is non-compliant," document, "patient declined 1800 blood glucose check, stating 'I don't want to be poked again tonight.'" Use objective language to describe what you saw, heard, or measured. Quote patients directly when their words are clinically relevant. Keep narrative notes focused on one event per note. Do not use narrative notes as a diary for the entire shift. Each note should represent a discrete clinical event with a beginning, middle (what you did), and end (the outcome or plan).

What NOT to Use Narrative Notes For

Do not use narrative notes for data that belongs in structured fields. Vital signs go in the vitals section. Medication administration goes in the MAR. Assessment findings go in the assessment section. Education goes in the education documentation. If the data has a structured home, put it there. Structured fields are searchable, trendable, and feed clinical decision support. Narrative notes are none of those things. Burying a blood pressure reading in a narrative note means the next nurse, the provider, and any clinical alerts will miss it. The rule is simple: structured data goes in structured fields; narrative notes are for context, reasoning, and events that have no structured home.

Common Mistakes

"Patient educated" with no details

Weak: Patient educated on medications.
Strong: Patient educated on metformin 500mg BID: purpose (blood glucose control), timing (with meals), common side effects (GI upset, diarrhea), and when to hold (NPO status, contrast dye procedures). Method: verbal with written handout (pharmacy medication guide). Patient response: verbalized understanding. Teach-back: patient stated, "I take it with breakfast and dinner to help my sugar, and I stop it if I'm not eating or getting a scan." Teach-back accurate. No barriers identified.

"Patient educated on medications" contains zero evidence that education occurred. It does not identify which medication, what was taught, how the patient responded, or whether they understood. A surveyor reading that note has no basis to confirm the education happened.

Skipping teach-back verification

Weak: Educated patient on wound care. Patient verbalized understanding.
Strong: Educated the patient on surgical wound care: daily dressing change with clean technique, signs of infection (redness, warmth, drainage, fever). Demonstrated dressing change; the patient performed a return demonstration using the correct technique. Teach-back: the patient stated, "I change the bandage every day after my shower, and I call the doctor if it gets red, hot, or starts draining stuff that looks like pus, or if I get a fever." Teach-back was accurate.

"Patient verbalized understanding" is not teach-back - it is your interpretation of what the patient said, without any evidence. Teach-back requires the patient to restate or demonstrate the information, and you to document what they said or did.

Document Barriers When They Exist

Weak: Educate the patient on insulin self-injection through demonstration and return demonstration.
Strong: Educate the patient on insulin self-injection through demonstration and return demonstration. Identify barrier: the patient has moderate hand tremor (essential tremor per history). Accommodate by practicing injection technique using an insulin pen (vs. syringe) for easier grip. The patient performed a successful return demonstration with the pen device. Teach-back: the patient stated the correct injection site rotation pattern. Place a referral to occupational therapy for adaptive technique assessment.

Documenting barriers when they clearly exist indicates thorough assessment. For example, a patient with a hand tremor learning insulin injection faces a physical barrier. By documenting the barrier and the accommodation, you demonstrate an individualized education plan.

Missing a discharge teaching topic

Weak: Discharge teaching completed. Patient verbalized understanding of all instructions. Discharge packet provided.
Strong: Discharge teaching completed covering: (1) Diagnosis - CHF exacerbation, (2) Medications - reviewed all 6 discharge meds with teach-back, (3) Follow-up - cardiology in 7 days, PCP in 14 days, (4) Activity - no lifting >10 lbs x 2 weeks, (5) Diet - 2g sodium restriction, (6) Wound care - N/A, (7) Warning signs - weight gain >2 lbs/day, increased SOB, edema, (8) When to call - provider office and 911 criteria reviewed, (9) Equipment - daily weight scale provided, (10) Contacts - cardiology office, nurse line, pharmacy numbers in packet. Teach-back performed on all topics. Written discharge instructions provided in English.

"Discharge teaching completed" without a topic list fails to document essential information. If a patient is readmitted and the receiving team inquires about what they learned regarding warning signs, a note stating "discharge teaching completed" offers no clarity. Each topic must be individually addressed and documented.

Narrative notes for data that belongs in structured fields

Weak: Narrative note: BP 162/94 at 1400. Patient reports headache 6/10. Administered hydralazine 10mg IV per PRN order at 1410. BP 138/82 at 1440.
Strong: Vital signs documented in the vitals flowsheet. PRN medication documented in the MAR. Narrative note: "1400 - Patient reported sudden-onset headache 6/10 with BP 162/94. MD Smith notified at 1405. Order received for hydralazine 10mg IV x1. Post-administration BP 138/82 at 1440, headache resolved to 1/10. Patient instructed to call if headache returns. Will continue to monitor BP q30min x 2 hours per telephone order."

The weak example buries vital signs and medication administration in a narrative note where they are not searchable or trendable. The strong example puts structured data in structured fields and uses the narrative note for what it is designed for: the clinical story, provider communication, and the plan.

Case Example

Ms. OkekeAge 64 — Newly diagnosed type 2 diabetes mellitus
fictional patient

Scenario

Ms. Okeke is being discharged after a 3-day admission for hyperglycemia (BG 487 on admission) that led to her new diagnosis of T2DM. She has no prior diabetes education. Her daughter, Adaeze, is present and will help with care at home. You are conducting the discharge teaching session. Ms. Okeke speaks English fluently but reports she "never finished high school." She wears reading glasses and has no cognitive deficits.

Chart Entry

Discharge Teaching Session - 1030-1145
Patient: Ms. Okeke. Daughter Adaeze present and participating.
Barriers assessed: Patient reports limited formal education ("never finished high school"). Health literacy screening: patient can read medication labels with reading glasses but prefers verbal instruction with pictures. Accommodation: all education provided verbally with pictorial handouts; written materials at a 5th-grade reading level selected from the diabetes education library. No cognitive, language, or hearing barriers identified.

1. Diagnosis - Type 2 Diabetes Mellitus
Topic: What T2DM is, how it affects the body, and that it is manageable with medication, diet, and monitoring.
Method: Verbal explanation with ADA pictorial handout "What Is Type 2 Diabetes?"
Patient response: Patient asked, "So my body still makes insulin but it doesn't work right?" - confirmed correct understanding.
Teach-back: Patient stated, "My pancreas makes insulin but my body can't use it like it should, so sugar builds up in my blood. I have to take medicine and watch what I eat to keep the sugar down." Teach-back accurate.

2. Medications - Metformin 500mg PO BID, Glipizide 5mg PO daily
Topic: Name, dose, frequency, purpose, timing, common side effects, and when to hold each medication.
Method: Verbal with pharmacy medication guides. Pill identification performed with actual discharge medications.
Patient response: Patient identified both pills by appearance. Asked, "What happens if I miss a dose?" - educated on missed dose protocol.
Teach-back: Patient stated, "The big white one is metformin, I take it with breakfast and dinner for my sugar. The little white one is glipizide, I take it every morning before I eat. If my stomach gets upset from the metformin I call the doctor, I don't just stop it." Teach-back accurate. Daughter Adaeze also identified both medications.

3. Blood Glucose Monitoring
Topic: How to use the glucometer, when to test (fasting and 2h post-meal), target ranges, and what to do with high and low readings.
Method: Demonstration of the glucometer by the nurse; return demonstration by the patient.
Patient response: Patient performed the return demonstration with correct technique on the second attempt (first attempt: insufficient blood sample, re-educated on lancing depth). Patient correctly read the result from the display.
Teach-back: Patient stated, "I check my sugar when I wake up before eating and two hours after dinner. If it's under 70 I drink juice and recheck. If it's over 300 I call the doctor." Teach-back accurate. Blood glucose log provided; patient demonstrated correct entry.

4. Diet - 1800-Calorie Diabetic Diet
Topic: Carbohydrate awareness, meal spacing, reading nutrition labels, and foods to limit.
Method: Verbal with pictorial plate method handout; reviewed sample meal plan with the patient.
Patient response: Patient stated, "I'm going to have to change how I cook - we eat a lot of rice." Discussed culturally appropriate modifications (portion control for rice, adding vegetables, reducing sweetened beverages). Patient receptive.
Teach-back: Patient demonstrated the plate method using the handout: "Half the plate is vegetables, a quarter is my protein, and a quarter is my starch like rice or bread. And I don't drink the sweet tea anymore." Teach-back accurate. Dietitian referral placed for outpatient follow-up.

5. When to Call the Doctor
Topic: Symptoms requiring a call to the provider (persistent BG >300, BG <70 not responding to treatment, signs of infection, and illness affecting eating or medication).
Method: Verbal with written "When to Call" card.
Teach-back: Patient stated, "I call if my sugar stays over 300, if it goes low and the juice doesn't fix it, if I get sick and can't eat or keep my medicine down, or if I get a cut that won't heal." Teach-back accurate. Daughter stated she will also keep the card on the refrigerator.

6. Follow-Up Appointments
Topic: Endocrinology appointment in 1 week, PCP in 2 weeks, lab work (HbA1c, metabolic panel) before the PCP visit.
Method: Verbal with printed appointment summary.
Patient response: Patient confirmed she has transportation arranged with her daughter for both appointments.
Teach-back: Patient stated correct dates and locations for both appointments and knew to get lab work done "the day before I see my regular doctor." Teach-back accurate.

7. DKA Warning Signs
Topic: Signs of diabetic ketoacidosis (nausea/vomiting, fruity breath, deep rapid breathing, confusion, abdominal pain) and that this is a 911 emergency.
Method: Verbal with pictorial warning signs handout.
Patient response: Patient appeared concerned; reassured that DKA is preventable with medication adherence and monitoring.
Teach-back: Patient stated, "If I start throwing up and can't stop, or my breathing gets fast and deep, or I get confused, my daughter calls 911. Don't drive to the hospital, call 911." Teach-back accurate. Daughter verbalized the same understanding.

Overall assessment: Patient and daughter engaged throughout the 75-minute teaching session. All 7 topics covered with teach-back verified on each. Patient demonstrated glucometer use via return demonstration. Barriers addressed (health literacy accommodation with pictorial materials). Discharge packet provided, including all handouts reviewed, medication list, appointment summary, When to Call card, and blood glucose log. Patient stated she feels "nervous but ready." Follow-up reinforcement planned at the endocrinology visit in 1 week.

Key points from above chart entry

Barriers assessed at the start:
Health literacy barrier identified, documented, and accommodated BEFORE teaching began - not as an afterthought.
Each topic has all 5 elements:
Every one of the 7 topics includes the specific content taught, the method, the patient response, teach-back with a direct quote, and barrier awareness.
Direct patient quotes for teach-back:
Using the patient's actual words ("My pancreas makes insulin but my body can't use it like it should") is stronger documentation than "patient verbalized understanding."
Failed first attempt documented:
The glucometer return demonstration failed on the first try. Documenting the failure, the re-education, and the successful second attempt shows thorough teaching - not a gap.
Family involvement documented:
Daughter's presence, participation, and understanding are documented throughout. This proves the caregiver was included in discharge planning as CMS requires.
Cultural accommodation:
Dietary teaching addressed the patient's actual eating patterns ("we eat a lot of rice") with culturally appropriate modifications rather than generic instructions.

Pro Tips

  • Document During or Immediately After the Teaching Session: You will not remember teach-back quotes and patient responses at the end of a 12-hour shift. Document these details while the conversation is fresh, even if you make brief notes on a paper brain that you later transcribe into the chart within the hour. Waiting until the end of your shift turns specific documentation into vague summaries.
  • Use Actual Patient Quotes for Teach-Back: Direct quotes provide the strongest evidence of teach-back. For example, "Patient stated: 'I take the water pill in the morning so I'm not up all night'" is observable and verifiable. In contrast, "Patient verbalized understanding of medication timing" reflects your interpretation. Writing quotes takes only seconds longer but significantly strengthens your documentation during a chart review or deposition.
  • Document failed teach-back - it is not a charting failure: A patient who cannot accurately teach back after the first explanation represents a normal finding, not a documentation issue. Document as follows: "Initial teach-back inaccurate - patient stated warfarin is for blood pressure. Re-educated: warfarin is a blood thinner to prevent clots. Repeat teach-back accurate." This demonstrates that you identified and addressed a knowledge gap. Only documenting the successful attempt obscures the gap and results in weaker documentation.
  • Use a Discharge Teaching Checklist to Avoid Missing Topics: A 10-topic discharge teaching checklist (diagnosis, medications, follow-up, activity, diet, wound care, warning signs, when to call, equipment, contacts) serves as your safety net against omissions. Work through it systematically. If a topic does not apply, document "N/A" along with a brief reason. An intentional "N/A" differs from a missing topic - one reflects a clinical decision, while the other indicates a gap.
  • Keep Education Documentation and Narrative Notes Separate: Education events belong in the education section of your chart. Use narrative notes for clinical events, provider communication, and context. Mixing the two places your education documentation where a surveyor does not expect to find it, while cluttering your narrative notes with teaching details. If a teaching session involved a notable event, such as a patient becoming upset, refusing further education, or family conflict about the care plan, document the teaching in the education section and the event in a narrative note, cross-referencing each other.

Frequently Asked Questions

What are the 5 elements of patient education documentation?
Every patient education event requires documentation of 5 key elements: (1) the specific topic taught, (2) the method used to deliver the education (verbal, demonstration, written materials, video), (3) the patient's response (what you observed), (4) teach-back verification (the patient restating or demonstrating the information in their own words), and (5) identified barriers to learning and the accommodations made. Missing any of these elements results in incomplete documentation that may not meet Joint Commission or Centers for Medicare & Medicaid Services (CMS) requirements.
What is the teach-back method?
Teach-back is a technique in which you ask the patient to explain what you just taught them in their own words or to demonstrate a skill you just showed them. This method verifies understanding instead of relying on the question, "Do you understand?" (which patients almost always answer yes to). Research by Schillinger et al. (2003) found that patients with diabetes whose physicians used teach-back had significantly better blood sugar control. To document teach-back, record the patient's actual words or describe their return demonstration, noting whether the teach-back was accurate or required re-education.
What goes in a narrative note vs. education documentation?
Teaching goes in education documentation, and clinical events that do not fit structured fields go in a narrative note. Education documentation captures what you taught, how you taught it, the patient's response, teach-back results, and any barriers encountered. Narrative notes document clinical events, observations, and reasoning, such as changes in condition, provider communication, patient interactions, incidents, and clinical decision-making. For example, if you taught a patient about wound care, that information belongs in education documentation. However, if the patient became upset during the teaching and refused further education, you would record the teaching in education documentation and the refusal in a narrative note.
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