By Coverys Risk Management

Your patients might not fully understand some of the essential patient education materials you provide if the documents are written at reading levels that are inappropriate for the average reader. Using plain language principles can help you create documents that all patients can easily understand.

Understanding Health Literacy Levels

The CDC defines personal health literacy as “the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.”

The National Assessment of Adult Literacy (NAAL) assessed the health literacy of more than 19,000 adults. Scores were broken down into four categories: proficient, intermediate, basic, and below basic.
The study found that only 12% of adults have a proficient level of health literacy, 53% have an intermediate level of health literacy, and 14% have a below basic level of health literacy. Health literacy levels were not the same across all demographics. People who spoke languages other than English before starting school, adults over age 65, and adults who had not graduated from high school or obtained a GED tended to have lower health literacy rates.

This means that 88% of the population may struggle with lengthy, complex, and abstract texts and documents. In some populations, an even higher percentage of individuals are likely to struggle.
According to the Center for Plain Language, the average U.S. adult reads at a seventh- to eighth-grade level. Because this is the average, many people will fall below this level. Risk managers often recommend that patient education documents be written at a fifth-grade reading level.

However, this does not always happen. According to a research study, Readability of Patient Education Materials on the American Association for Surgery of Trauma Website, only one article had a reading level that was below the eighth-grade level, and the mean reading grade level was 10.9.

Plain Language Helps Patients Succeed

According to, plain language can help readers find what they need, understand what they find on the first reading, and use what they find to meet their needs.

This is extremely valuable in patient-focused healthcare documents. For example, let’s say you’re giving a patient a document on post-surgery care directions. These instructions provide vital information on things like medication, wound care, food, and safe activity. If the patient does not understand the instructions, they may not manage their post-surgery care successfully. This could lead to bad outcomes for the patient, and it may increase the likelihood of medical malpractice claims.

The Hallmarks of Plain Language

The Plain Writing Act of 2010, which called for plain language in government documents, defines plain language as “Writing that is clear, concise, well-organized, and follows other best practices appropriate to the subject or field and intended audience.” provides in-depth writing guidelines, templates, and checklists on using plain language. Some of the most common techniques include the following:
  • Organization that is reader-centered.
  • Use of “you” and other pronouns.
  • Use of the active voice instead of the passive voice.
  • Use of short sentences and paragraphs.
  • Use of familiar words.
  • Use of headers, lists, tables, and other easy-to-follow design features.

Your Documents Might Not Be as Readable as You Think

If your documents rely on long sentences with complex grammatical structures and multisyllabic jargon, it should be fairly easy to recognize that the reading level might be inappropriate for the average patient seeking medical care. However, even if your documents use short sentences and small words, you might still have a readability problem.

Organization is key. An overly lengthy list of instructions can be difficult to scan.
  • Use headings and subheadings to break lists down into logical groups.
  • Use list types that suit the information. For example, numbered lists make sense for instructions that have a sequential order.
Both vocabulary and content are important.
  • Don’t provide unnecessarily complex information. Stay focused and direct.
  • Use simple words in place of more advanced vocabulary and medical jargon.
  • Make instructions clear and direct by using strong action verbs instead of “should.” For example, “do not swim for six weeks after surgery” is better than “the patient should not swim for six weeks after surgery.” The latter could be misunderstood as a mere recommendation that does not need to be followed.
Font can also matter.
  • Print that is too small to read can be a barrier to understanding. Use a 12-point font or larger.
  • Use design elements, such as bold or enlarged fonts, to draw attention to key pieces of information.

Assess Your Patient Documents

The best way to determine whether your patient documents use plain language is to have a few different people critically analyze them to:
  • Identify vague, confusing, or advanced words. Keep in mind that short words can also be advanced. For example, “adverse” is only two syllables, but “bad” is a much more common alternative. Looking at your document, how many words have more than two syllables? How many words have only one or two syllables but are still advanced? What are the most challenging words?
  • Look at the sentence and paragraph length. How many words are in each sentence? How many sentences are in each paragraph? Can sentences and paragraphs be shortened? Aim for sentences that are no longer than 20 words.
  • Consider the goal of plain language. Can the patient find what they need and understand what they find on the first reading? Does the information meet their needs? To determine this, identify the key intended takeaways. Are the intended takeaways prominent and obvious? Is this information organized clearly? Are headings and subheadings used so that the patient can scan for information easily? Are directions stated as directly as possible with strong action verbs?
The use of plain language can improve patient outcomes and reduce medical liability.
This article was, in part, based on the Coverys presentation “Cut the Gobbledygook for Safe Patient Care,” presented by Robin Webster, MHA, BSN, RN, CPHRM, and Marlene Icenhower, BSN, JD, CPHRM.

Copyrighted. No legal or medical advice intended. This post includes general risk management guidelines. Such materials are for informational purposes only and may not reflect the most current legal or medical developments. These informational materials are not intended, and must not be taken, as legal or medical advice on any particular set of facts or circumstances.