Congress Abstracts 2006

279

FROM PAPER TO ELECTRONIC: A HOSPITAL'S JOURNEY TO IMPROVE CHEMOTHERAPY ADMINISTRATION DOCUMENTATION AND PATIENT SAFETY. Mina Ford, RN, MSN, OCN^® , Martha Jefferson Hospital, Charlottesville, VA.

Over the past five years, Martha Jefferson Community Hospital has been in the process of transitioning to a paperless documentation system. Electronic chemotherapy documentation forms were created with the goals to improve documentation and patient safety.

The goals of the interdisciplinary team were to make charting more accessible to the nurses, to improve the consistency of documentation of chemotherapy administration hospital-wide, to have quick and easy access to patients past experiences with chemotherapy, and to improve the safety of chemotherapy administration throughout the hospital.

The team developed three separate forms: chemotherapy pre-administration, chemotherapy post-administration, and chemotherapy double-check. All forms can be viewed by nurses, pharmacists, and physicians. This allows better access to patient information. The forms have required fields so nurses are unable to sign the forms until all areas are complete which ensures more complete documentation. The forms also have the ability to contain a large amount of reference text that was used to pull out pieces of hospital policy and procedure as quick references. This aspect allows the form not only to record data, but to educate the nurses as well. An additional section was added to monitor the patients' response to the chemotherapy that allows everyone the ability to review patients past experiences with chemotherapy and their responses. Sections for adverse drug reactions and education are also available in the form so nurses do not have to open another form.

In-services and a tutorial will be available for all staff when the forms are implemented. Team members will work with the staff if any problems develop and a survey will be sent three months after the forms are implemented for staff feedback.