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2.5. Writing patient instructions (Writing)

Learning Objectives

At the end of the lesson, students will be able to:

  • identify and articulate key elements that contribute to clear and effective patient instructions and clinical documentation.
  • describe the importance of clarity, simplicity, and cultural sensitivity in patient communication.
  • analyze examples of patient instructions to identify strengths and weaknesses in clarity and accessibility.
  • create clear, concise, and culturally sensitive patient instructions for a specific medication.
  • demonstrate the use of appropriate medical terminology while maintaining clarity and conciseness in clinical documentation.

 

Part 1: Warm-Up Brainstorm

Key Elements of Patient Instructions
On the right column of the table below, list of key elements that should be included in patient instructions. Why do you think this elements are important, write your ideas in the table below.

Key Element Why it is important
clarity Ensures the patient understands the instructions fully
Simplicity
Cultural sensitivity
Visual Aids
Actionable steps
Follow-up information
Time frames

Part 2: Analyzing Sample Patient Instructions

Identifying Strengths and Weaknesses: Analyze the two patient instruction samples below. Highlight what works well and what could be improved. Use the prompts to guide your analysis.

Sample 1

Take 1 tablet of Lisinopril (10 mg) every morning with water. Avoid taking it on an empty stomach. If you feel dizzy, sit down and rest. Contact your doctor if the dizziness continues.”

Sample 2

Take your meds every morning. Don’t eat before. If you feel bad, call someone.

Prompts

  • Is the language clear and simple?
  • Does it include necessary details?
  • Are there any cultural concerns?
  • Suggestions for improvement?

Part 3: Writing clear instructions

Writing Clear Instructions: You will be assigned the task of writing patient instructions. First, study the template.

Template for Patient Instructions:

  1. Introduction: What is the procedure or medication for?
  2. Step-by-Step Instructions:
    • Step 1: ___________________________________________
    • Step 2: ___________________________________________
    • Step 3: ___________________________________________
    • Step 4: ___________________________________________
  3. Important Notes:
    • What to Do If Something Goes Wrong:

Example: Administering insulin

Introduction This guide explains how to administer insulin safely.
Step-by-Step Instructions:
  1. Pinch the Skin (optional): If preferred, pinch the skin to create a fold.
  2. Insert the Needle: Hold the syringe at a 90-degree angle (or 45 degrees for thinner patients) to the skin and quickly insert the needle.
  3. Inject the Insulin: Push the plunger down to administer the insulin. Ensure you inject the full dose.
  4. Withdraw the Needle: Pull the needle out quickly at the same angle it went in.
Important Notes: Store your insulin in the refrigerator, but never freeze it.
What to Do If Something Goes Wrong If you feel confused, check your blood sugar and call your doctor immediately.

Now, write patient instructions for one of the below procedures. Use the template below to ensure clarity, simplicity, and cultural sensitivity.

Options for Procedures:

  • Caring for a wound after surgery
  • Taking antibiotics
  • Using a nebulizer
  • Monitoring blood sugar levels

 

Part 4: Writing Clinical Summaries: Composing a Clinical Summary

Read the case study below and use the template to write a clinical summary. Include patient history, diagnosis, treatment, and follow-up instructions. Be concise and use appropriate medical terminology.

Patient Name: Sarah Johnson
Age: 45
Medical History: Type 2 diabetes, hypertension
Diagnosis: Diabetic foot ulcer (infected)
Treatment: Cleaned wound, prescribed antibiotics, recommended weekly check-ups
Follow-Up Instructions: Keep the wound clean, avoid walking barefoot, monitor blood sugar levels, contact the clinic if redness or swelling worsens.
Clinical Summary Template:

1. Patient Information:
* Name: _____________________________________
* Age: ______________________________________
2. Medical History:
3. Diagnosis:
4. Treatment Provided:
5. Follow-Up Instructions:

Clinical Summary Template:

  1. Patient Information:
    • Name
    • Age
  1. Medical History:
  2. Diagnosis:
  3. Treatment Provided:
    Follow-Up Instructions:

Part 5: Peer review and feedback

Exchange your patient instructions or clinical summaries with a partner. Use the checklist below to provide constructive feedback.

Feedback Checklist Yes/No Comments
Are the instructions/summaries clear?
Is the language simple and concise?
Are all necessary details included?
Does it avoid unnecessary jargon?

 

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Basic Skills for Clinical Medical Assistant Copyright © 2025 by Montgomery College is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

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