Standardization of Electronic Nursing Documentation in Radiation Oncology
Hyun Soo Chae, BSN, ME, RN, OCN; Pamela Birch, BSN, RN, OCN; Cynthia Franklin, ASN, RN; Marilyn Ayoob, BSN, MS, RN
Radiation Oncology, MedStar Georgetown University Hospital
The importance of accurate nursing documentation goes beyond meeting legal requirements. Consistent and clear nursing documentation is essential to providing high-quality, continuous patient care (Kammie, 2007). The electronic medical record (EMR) enhances the effectiveness of interdisciplinary collaboration, especially among nurses and physicians (Green & Thomas, 2008).
PURPOSE OF THE PROJECT
The radiation oncology department at MedStar Georgetown University Hospital is divided into specialized teams based on cancer type and tumor location. Nursing assessments of radiation toxicity are site-specific and individualized. After the transition from paper-based charts to EMR, assessment documentation was often inconsistent or incomplete. The standardization project was initiated to ensure continuity of care across specialized treatment teams.
DATA COLLECTION & ANALYSIS
1.Standard nursing documentation form:
The nursing team collaboratively developed a standard nursing documentation form in the EMR based on the department policy and literature review. The “Nursing Assessment Encounter” form contains six (6) essential assessment components for all patients: patient education, medications, allergies, radiation toxicity, performance status, and skin assessment (see Fig. 2). This form was designed to be completed weekly at patient simulation, on-treatment-visit (OTV), or end-of-treatment (EOT) visit.
After the first week, 28.9% of the nursing documentation events contained all required documentation elements. The rate increased to 71.7% at week two, and reached over 80% for weeks three through five. After four months of monitoring, the rate of completion improved and stabilized at 90%, and the weekly audit was concluded.
1.Over the course of the audit, drops in documentation correlated to periods when nurses provided care for other nurses’ patients due to vacations or unplanned leave.
The standardization of nursing documentation project accomplished consistency and continuity of the completion of essential nursing documentation. Success can be attributed to extensive nursing communication with the EMR team for tool development and vigorous reassessment of the necessity of each documentation element at different patient visits.