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Standardization of electronic nursing documentation in radiation oncology

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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).



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.



1.Project proposal and literature review
2.Discussion: EMR team and Nursing team
3.Creation of a standard nursing documentation set (“Nursing Assessment Encounter”) in the EMR
4.Creation of a template document (“Nursing OTV Note”) within the encounter for data coordination and skin assessment
5.Group education session for nursing staff prior to implementation of the project, and additional individual session for each nurse
6.Weekly self-audit
7.Bi-weekly data review and discussion



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.

•A self-audit form was created for each member of the nursing staff to review the completeness of their own documentation on a weekly basis.
•A justification was required at the time of the self-audit when incomplete components were noted.
•Dedicated data manager ensured that self-audits were completed according to the prescribed documentation protocol.
3.Data analysis:
•One patient encounter is created per each patient per week.
•Must include: 1) Patient education at simulation appointment, and 2) Skin assessment at OTV
•Allowed to omit: 1) Toxicity assessment for single treatment, 2) Skin assessment for simulation visit, and 3) Education documentation except for simulation 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.

•Practice changes were implemented to divide patient workload by treatment plans and nursing tasks when covering for an absent nurse.
2.Ongoing improvements to increase efficiency:
•Simplify the encounter and its contents to reduce time to complete documentation
•Use of portable devices being considered
•Enhance the documentation template to further simplify and streamline the process


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.

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