Establishing an integrated framework for documentation: use of a self-reporting health history and outpatient oncology record.

The Nursing Documentation Committee at the Ottawa Regional Cancer Centre designed and implemented a self-reporting health history that provides baseline data for care planning and an outpatient oncology recore that provides ongoing documentation of all patient assessment findings and subsequent care.

Abstract

PURPOSE/OBJECTIVES: To describe the development and implementation of a succinct documentation system that provides all oncology team members with a quick and systematic approach to gathering information for care planning. DATA SOURCES: Published articles and books. DATA SYNTHESIS: The Nursing Documentation Committee at the Ottawa Regional Cancer Centre designed and implemented a self-reporting health history (SRHH) that provides baseline data for care planning and an outpatient oncology recore (OOR) that provides ongoing documentation of all patient assessment findings and subsequent care. The OOR combines flowsheet and progress note documentation on one form. These tools are used by all members of the oncology team. CONCLUSIONS: Through consistent use of the SRHH and OOR, quality of documentation has increased and nursing time spent on charting has decreased, thus enabling the oncology team to focus on direct patient care activities. Furthermore, enhanced communication among members of the oncology team has resulted in improved continuity of patient care. IMPLICATIONS FOR NURSING PRACTICE: The SRHH and OOR are time-efficient and cost-effective tools that can assist nurses in meeting legal, professional, and accreditation documentation standards.