Congress Abstracts 2004

8

DOCUMENTATION TOOLS: STAFF INVOLVEMENT + EVIDENCE BASED PRACTICE = SUCCESS. Kelley Gibson, RNC, BSN, OCN^®, Good Samaritan Hospital, Cincinnati, OH.

Documentation in the outpatient oncology setting is mandated, necessary, time consuming, and often not a priority. Gleaning meaningful information about an individual patient and/or trending outcomes across a department becomes a challenge. The additional demands by regulator agencies such as JCAHO, Medicare, insurance agencies, institutions, and other disciplines are overwhelming to a nurse who “just wants to take care of my patient.” Thus documentation becomes routine, mundane, and frustrating. Utilizing nursing staff’s experience and expertise is essential in order to produce a tool that promotes, prompts, and streamlines this process.
Nurses at a large multihospital community setting were interested in revising the outpatient documentation forms utilized at the two centers. A task force comprised of staff nurses, an oncology educator, and a quality coordinator was commissioned to review and revise the current tools.

The task force gathered input from staff, physicians, and pharmacists, literature reviews, ONS guidelines, and samples of forms from various settings. The end result was the development of a “six-cycle” pathway versus a one-visit pathway. This eliminated the documentation of repetitive outcomes and illustrates ongoing progression to measurable goals. Quality indicators were chosen and included for easier documentation and data retrieval. A consent form was developed to comply with ONS and ASCO recommendations. The team’s goal was to reduce duplicate charting where possible. Forms were combined and revised, patient education was added to the pathway, and the ambulatory summary was added to the medication record.

Periodic audits are done to demonstrated compliance. The pathway outcomes continue to be monitored and trended to develop best practice. Quality indicator data is collected and analyzed, and improvement strategies implemented. Staff evaluations have been positive—less repetition, less documentation time.

Staff involvement was essential to this project to highlight the redundancy of the forms and the components that were most beneficial to patient care. They also became aware of the rationale for some of the required components, which lead to better tools that will be utilized, accepted, and satisfying.