CINJ develops electronic documentation tool to improve patient care

A continuing challenge that oncology nurses face is providing clear documentation of patient care. In order to maximize their ability to improve patient outcomes, nurses at The Cancer Institute of New Jersey (CINJ) have developed an electronic documentation tool that integrates a number of key measurement and evaluation resources utilized in the oncology nursing field. The work was presented at the Oncology Nursing Society's (ONS) Annual Congress being held this week in New Orleans. CINJ is a Center of Excellence of the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School.

Documentation of patient care allows healthcare professionals to understand the care being provided, the effectiveness of interventions and any clinical problems that may need further resolution. Without well-structured documentation, it can be difficult for the healthcare team to improve the quality of care. CINJ Director of Oncology Nursing Services Janet Gordils-Perez, MA, APN-C, AOCNP, led a recent effort to enhance the documentation process of patient care at CINJ.

A comprehensive review of all current nursing documentation was completed. Forms were condensed and simplified into a user-friendly checklist format that prompts the nurse to complete an in-depth assessment using the Common Terminology Criteria for Adverse Events as a measurement tool, the NANDA-based nursing diagnosis and the ONS Putting Evidence into Practice® resources for evidence-based interventions and evaluation. CINJ nurses piloted the documentation tool and revisions were made after feedback was obtained.

Informal observations from nurses who utilized the new tool suggest increased satisfaction with recording data in this manner. Formal evaluations with audits are planned to ensure documentation is accurate, clear and complete and that standards of oncology nursing practice are met. Impact on patient outcomes also will be explored.

"It is critical for nurses to assume responsibility for the standards of their practice as well as documentation. They are accountable for providing evidence-based, quality nursing care and documenting these services. By providing a uniform documentation tool, we can ensure quality nursing care by using the strongest level of evidence on which to base nursing practice interventions. It also ensures that regulatory and institutional standards are being met," says Gordils-Perez. She notes the electronic documentation tool can be adapted for use by all outpatient care nurses nationally in order to benchmark quality measures and ensure streamlined, evidence-based documentation with the goal of improving patient outcomes that are directly affected by nursing care.