Congress Abstracts 2003

70

OUTPATIENT DOCUMENTATION FORMS FOR CHEMOTHERAPY AND RADIATION: COMPLYING WITH ONCOLOGY NURSING SOCIETY GUIDELINES. Jeanene G. Robison, MSN, RN, AOCN^®, OCN^®, and Connie Cook, RN, BSN, The Christ Hospital, Cincinnati, OH.

Documentation is an ongoing challenge for nurses who administer chemotherapy or care for patients receiving radiation therapy on an outpatient basis. ONS encourages the implementation of their guidelines and recommendations for practice in order to provide safe, effective patient care and to improve clinical performance.

Nurses from five hospitals, which are located in the Midwest region and which are part of a multi-hospital system, collaborated to develop two documentation tools. The purpose of these documentation tools was to promote consistency in documentation practices and to meet national standards for documentation on a consistent basis.

This committee of nurses included staff nurses, nurse managers, and an oncology CNS. Additional staff nurses, pharmacists, physicians, and risk management reviewed the documentation form for its usefulness and thoroughness. The form was revised based on their feedback, and was piloted at each facility. The final documentation tools are in the implementation phase.

Two documentation tools were developed. One tool, the “Oncology /Hematology Outpatient Flow Sheet,” was developed for use by nurses in both medical oncology and radiation oncology outpatient units. It includes areas to document vital signs, height/weight, BSA, chemotherapy and other meds, flush solutions, transfusions, and VAD site assessment and access. A second tool was developed for use by radiation oncology outpatient units and includes areas to document side effects related to radiation therapy and side effect management.

The documentation guidelines in the ONS Chemotherapy and Biotherapy book (2001) and in the ONS Manual for Radiation Oncology, Nursing Practice and Education (1998), which have been used as the basis for development of these documentation tools, will also be used as the basis for the performance improvement monitors. It is anticipated that documentation of practice and patient care will improve and will be standardized in each of the five facilities. This improvement will be evaluated through staff feedback and medical record evaluation.

Both of these documentation tools will be presented, and can easily be adapted for use in other medical oncology or radiation oncology settings. Staff feedback, performance improvement data, and logistical issues will also be presented.