Congress Abstracts 2006

96

AMBULATORY ONCOLOGY CHART AUDITS-PERFORMANCE IMPROVEMENT. Wendy Miano, MSN, ND, RN, AOCN^®, and Kathleen Chiarucci, RN, MSN, MBA, CPHQ, University Hospitals of Cleveland, Cleveland, OH.

JCAHO (Joint Commission Accreditation of Healthcare Organizations) requires periodic medical record review. In the Ambulatory Oncology setting, medical record documentation serves as the patient's primary record of chemotherapy and oncology care. In a large tertiary oncology ambulatory unit, Performance Improvement Initiatives have been drawn from a monthly chart audit.

Specific indicators are measured with each medical record audit (For example: Verbal Order authentication, Medication summary/Allergies; Pain Assessment and interventions/evaluation of effectiveness). In 2005, Performance Improvement Initiatives specific to monthly chart audits were identified. Two PI initiatives include: 1) Authentication of MD Verbal Orders; and 2) Pain Assessment and Management/Documentation Standard.

Described are the PI components specific to Verbal Order Authentication and Pain Management. Verbal Order Authentication required assessment of operational issues: Location of chart ('flagging chart for signature' versus faxing verbal order for signature (in satellite setting). Pain Assessment and Nursing Management required a formal Standard of Care authored by an Advanced Practice Nurse whose expertise is pain management. Monthly Pain Case Study In-services reinforced elements of pain assessment and management in very tangible, 'real life' case studies. A standardized Pain Flow Sheet (keyed with expected elements of pain assessment and management) was revised for ease of documentation, tracking interventions over time.

Evaluation of these PI initiatives has been streamlined through monthly audit reports. Positive and negative trends have provided timely feedback to PI components. For example, pain assessment documentation, with initial nursing education, improved dramatically. However, documentation of the pain interventions and tracking management over time was incomplete.

Ambulatory Oncology Chart Audits provide Performance Improvement Initiatives, which are based in nursing practice and documentation standards. A future development will be incorporating peer review given Chart Audit findings - raising the bar of Oncology Nursing Practice and Documentation.