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    Patient Experience

    Health Literacy and Discharge Instructions: Design Standards for Surgical Practices

    Per data from the National Assessment of Adult Literacy (NAAL), only about 12% of US adults have proficient health literacy skills, meaning the remaining 88% have basic, below basic, or only intermediate health literacy. Discharge instructions written at a college reading level for a patient who reads at a sixth-grade level create both a compliance gap and a patient safety risk. Federal law and accreditation standards address health literacy in patient education materials.

    Health Literacy Standards in Federal Regulation and Accreditation

    • The Plain Writing Act of 2010 (Pub. L. 111-274) applies to federal agencies and requires that federal communications use clear, plain language. While this law does not directly govern private medical practices, it established the regulatory expectation that CMS and other federal agencies apply to patient-facing materials they develop or require. CMS patient notice templates are written to a sixth-grade reading level.
    • The Joint Commission's Patient Education standards (PC.02.03.01) require that patient education account for the patient's literacy level, language, learning needs, and learning barriers. A practice that provides the same discharge packet to every patient regardless of assessed literacy level does not satisfy this standard.
    • Section 1557 of the Affordable Care Act prohibits discrimination on the basis of national origin in health programs receiving federal financial assistance. Federal courts and HHS have interpreted this to include an obligation to provide meaningful access to health information, which in practice means translating or interpreting discharge materials for patients with limited English proficiency. AHRQ links limited English proficiency and low health literacy as compounding factors in discharge comprehension failure.
    • The National Academy of Medicine defines health literacy as the degree to which individuals can obtain, process, and understand basic health information and services to make appropriate health decisions. Provider-side health literacy includes the organization's capacity to create and communicate clear health information, which is distinct from the patient's individual literacy level.

    Measuring Readability of Discharge Materials

    • The Flesch-Kincaid Grade Level formula calculates the US school grade level required to comprehend a text passage. It is built into Microsoft Word (Review, then Check Accessibility, then Check Document) and available free at readability-score.com. Discharge instructions for surgical patients should target a grade 6 reading level. Research on discharge instruction readability has consistently found that hospital-generated materials test between grade 9 and grade 12, well above the recommended threshold.
    • The Gunning Fog Index measures sentence length and polysyllabic word frequency. A Fog Index above 12 (approximately college sophomore level) predicts poor comprehension in patients with average US literacy. Surgical discharge instructions frequently fail this threshold due to medical terminology: 'ambulate with gradual weight-bearing progression' reads at Fog Index 16, while 'walk a little more each day, starting with short distances' reads at Fog Index 6.
    • The SMOG Readability Formula (Simple Measure of Gobbledygook) is preferred for health education materials because it measures the years of education required to understand 100% of a text, while Flesch-Kincaid estimates only 50% comprehension. AHRQ recommends SMOG for patient education materials. Online calculators are available at readabilityscores.com.
    • Avoid relying solely on readability scores. A passage can score at grade 5 reading level while still using unfamiliar health concepts. Reading level and health literacy are related but distinct. A plain-language review that involves actual patients from your population testing draft materials provides validation that formulas cannot.

    Plain Language Principles for Discharge Instructions

    • Use active voice and direct address. 'Take your antibiotic twice a day with food' is clearer than 'The prescribed antibiotic should be taken twice daily with meals.' Active sentences are shorter, assign clear responsibility, and test at lower Flesch-Kincaid levels.
    • Limit each sentence to one idea. 'Do not drive, operate heavy machinery, or make important decisions for 24 hours after general anesthesia because anesthesia affects your judgment, reaction time, and coordination' should be split: 'Do not drive or operate heavy machinery for 24 hours after surgery.' Then: 'Anesthesia affects your judgment and reaction time for at least 24 hours.'
    • Replace medical terms with plain equivalents in the instruction text. Provide the medical term in parentheses if documentation requires it. Write 'keep the wound dry' rather than 'avoid wound maceration.' Write 'watch for signs of infection: redness spreading beyond the edges of the wound, yellow or green drainage, or fever above 101.5 degrees' rather than 'monitor for surgical site infection indicators.'
    • Use numbered steps for sequential instructions. Wound care that involves five steps is easier to follow when presented as 1, 2, 3, 4, 5 than as a paragraph. Numbered steps also help a patient find their place in the process if interrupted.
    • Include visual aids for procedural instructions. A photograph of what a healing incision looks like at day 3 versus a concerning incision communicates more reliably than text descriptions alone. The Joint Commission explicitly lists visual aids as appropriate education methods in the PC standards.

    Designing for Low-Literacy and Low-Health-Literacy Populations

    • Use a sans-serif font (Arial, Calibri, or Helvetica) in at least 12-point size for printed discharge materials. Per AHRQ's Health Literacy Universal Precautions Toolkit, serif fonts and small type sizes reduce comprehension in patients with vision impairment or low literacy.
    • Limit each page to one or two key concepts. Handing a patient a 12-page discharge packet increases information overload regardless of literacy level. Prioritize the three to five actions the patient must take in the first 48 hours, and reserve detailed wound care or medication information for a separate reference page.
    • Test your discharge materials with patients before implementation. AHRQ recommends cognitive interviewing, a method in which a researcher or clinical staff member asks patients to read a draft document aloud and explain what each section means in their own words. Comprehension gaps identified during cognitive interviews predict real-world misunderstanding far more accurately than readability formulas.
    • Implement the Universal Health Literacy Precautions approach: treat every patient as if they may have difficulty understanding health information, regardless of their apparent education level or communication style. Patients with high education levels can still have low health literacy in areas outside their expertise, and low-literacy patients may not disclose difficulty to avoid embarrassment.
    Related
    Language Access Requirements for Medical and Surgical PracticesPediatric Aftercare: Structuring Discharge Instructions for Parents and CaregiversHCAHPS and Discharge Instruction Quality: How Aftercare Documentation Affects Hospital Ratings
    Frequently asked

    Questions patients ask.

    Is there a federal requirement for the reading level of discharge instructions?

    No federal regulation specifies an exact reading grade level for discharge materials. However, CMS guidance, AHRQ recommendations, and Joint Commission patient education standards collectively create an expectation that materials be written at a level appropriate to the patient population served. AHRQ recommends targeting a sixth-grade reading level for general patient education materials. Facilities that provide materials clearly above the comprehension level of their patient population create a documentation and malpractice vulnerability.

    Does low health literacy qualify as a learning barrier requiring documentation?

    Yes. Joint Commission Standard PC.02.03.01 and CMS patient education requirements both require that learning barriers be identified and addressed. Low health literacy is an established learning barrier. If a literacy screen identifies a patient with limited literacy, that result should be documented, and the discharge education approach should be adapted accordingly: using simpler language, visual aids, and teach-back.

    What literacy screening tools are validated for clinical use?

    The Newest Vital Sign (NVS) is a 6-question health literacy screen that uses a nutritional label as the stimulus and takes approximately 3 minutes to administer. It is validated in English and Spanish. The Brief Health Literacy Screen (BHLS) uses three self-report questions and correlates strongly with objective literacy measures. The REALM-SF (Rapid Estimate of Adult Literacy in Medicine) asks patients to read and pronounce 7 medical words. All three tools are in the public domain and available through AHRQ's Health Literacy Measurement Tools resource.

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    This blog provides general information about healthcare compliance and aftercare best practices. It does not constitute legal, medical, or regulatory advice. Consult qualified professionals for guidance specific to your practice.