Study objectives: To determine the ability of emergency department patients to understand common written discharge instructions and the level of reading difficulty of standard discharge instructions. Design: The study was performed in two parts. In part 1, subjects were asked to read one set of standard written discharge instructions. Then, with the instructions to refer to, subjects were asked to answer five questions about the instructions. A subject's level of success was correlated with age, sex, and highest level of education. In part 2, 47 sets of standard written discharge instructions from six different EDs were computer analyzed using five commonly used readability formulas. Results were reported as grade levels. Setting: The ED of a large inner-city university hospital. Type of participants: The subjects for part 1 were 400 adult ED patients who presented on randomly selected days. Measurements and main results: Part 1: A significant proportion of patients failed to answer correctly at least four of five questions. Patients educated beyond high school demonstrated higher levels of success than did those with less education. A trend was noted for younger subjects to perform better than older subjects. The answers to the three most frequently missed questions were contained within areas of difficult sentence structure or long paragraphs containing large amounts of information. Part 2: The average grade level required to understand instruction sheets ranged from 6.0 to 13.4. More difficult instruction sheets tended to contain numerous multisyllabic words, long sentences, and difficult sentence structure. Conclusion: A significant proportion of ED patients have a demonstrable inability to understand common written instructions. ED instruction sheets are written at a level of difficulty that is out of the readable range for many patients. Health care providers should strive to simplify written materials and to develop new methods for instructing those for whom current written materials have no meaning.
