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Nursing documentation in Radiation Oncology

  • 1.  Nursing documentation in Radiation Oncology

    Posted 05-20-2019 07:52
    I was wondering what policies exist regarding nursing documentation in radiation oncology.
    Do your nurses do a full nursing assessment on initial consult? Do they just touch on meaningful use questions?
    Trying to establish some guidelines in our busy practice with few nurses and what I can help eliminate so more time is spent on education and side effect management.

    Annette Quinn, RN, MSN

    Program Manager, Radiation Oncology

    UPMC Hillman Cancer Centers

  • 2.  RE: Nursing documentation in Radiation Oncology

    Posted 05-21-2019 11:05
    ​Hi Annette!

    We are a small hospital bases radiation center with one Rad onc, one full time RN and one flexi  :-)  Census stays around 35-40 patients on treatment.  We do not currently have a policy stating how I should document.  Since I am the only RN, I am the one to enter all medical/surg /family history,medications etc and I try to do that the day before the appointment so I can just update during the visit.  I do all my documentation in Aria.
    For my assessment I do by exception to make it more efficient and less time consuming. I also review the NCCN distress scale and assess how their coping emotionally, physically and financially to be able to refer them to our resources (social worker, dietician, physical therapy, Oncology rehab, Lymphedema clinic etc) as needed.
    I evaluate ECOG, VS, update history, pain assessment/medications, distress, assess for pacemakers and document for physicist, and make sure patients have appointments with medical oncology, pending or needed scans,  and I also schedule for our CT sims and follow ups.  Most of that is done on initial consult.  It usually takes 15-20 minutes one on one and the rest I can do as time permits, leaving at least 40 minutes for the rad onc time.  I also do all survivorship care plans for our follow up clinic on Fridays.  Again no policy, I just do any and everything I can to keep me and the rad onc and therapist running like a machine:-)  I have made a lot of changes since I started here to the education the patients receive and some days it is difficult, I just prioritize the patients needs at that time.
    Education I try to do on regroup appointments or I catch them while they are here for ct sim or treatment.  Head and neck patients I will schedule time with them if possible since teaching is much more involved.  I have simplified some education material so it's not so overwhelming to the patient and I use the OTV days to reiterate teaching throughout the patients treatment.  Also, if a patient has questions the therapist will place them in a room for me to see in between consults and other appointments.
    Admin may be changing this soon because our billing department does not have access to Aria and cannot see my documentation.  I may start filling in documents that will interface to EPIC system for billing purposes and they may develop a policy at that time.

    Hope this helps... I know it's way more than you asked for.  I'll be interested to hear if other practices have such a policy.

    [Heather] [Hyler]
    [RN OCN]
    Chesapeake VA

  • 3.  RE: Nursing documentation in Radiation Oncology

    Posted 05-22-2019 05:58
    Although I recently retired, I worked in a similar situation. All of our documentation was in Aria. The nursing assessment, vital signs, medication reconciliation, medical and social assessment, distress assessment were done on the day of the consult. We used journal notes to communicate between disciplines and document phone calls, change in status or procedures that may have taken place or are scheduled. There was also a Resource List which was used to document what education materials were provided.
    Stephanie Bino, RN BS OCN
    Sent from my iPad

  • 4.  RE: Nursing documentation in Radiation Oncology

    Posted 05-21-2019 12:37
    Hi Annette,

    We had EPIC go-live when I started in this department and that turned a lot of policies on their head. It has been a challenge that EPIC does not communicate with ARIA, our treatment software. Medical oncology doesn't know where the patient is in their radiation treatment or when treatment is starting or finishing from ARIA, but they can read my notes. Likewise, I was given access to the chemotherapy treatment area notes that the radiation therapists didn't have, or didn't have the training to understand. I include a small careplan section and I cut and paste then update each note. I get told by the other services that this is very helpful for them.

    Diagnosis: ***

    Chemotherapy: ***. @CAPHE@ has received *** doses of ***. ***

    Radiation Therapy: ***. @CAPHE@ has received ***cGy.

    I have been able to keep how much time I spend on a note down by using smartphrases. This is one I use for triage in person, four keystrokes brings up the medical history and other diagnoses, the most recent radiology, labs, the last 12 weights in a table, and a table with the vital signs taken that encounter.

    @M@ @FNAME@ @LNAME@ is a @AGE@ @SEX@, here today for ***.

    @CAPHE@ has a past medical history significant for: @PMH@
    Current Problem List: @PROB@





    @M@ @LNAME@'s most recent chest CT:

    Carotid U/S

    @ME@, RN OCN
    Radiation Oncology

    This one was written for the sarcoma service, just to keep the documentation quick to let us focus on the care.

    @M@ @FNAME@ @LNAME@ is a @AGE@ @SEX@, seen in clinic today by Dr {blank single:19197::"Brigman","Eward","***"} for post-op evaluation of ***.

    Incision: {blank multiple:19196::"clean","dry","intact","pink","well approximated","reddened","swollen","tender","non-tender","oozing","***"}, with {blank single:19197::"***","no odour","foul odour","necrotic odour"} and {blank single:19197::"no drainage","purulent drainage","sanginous drainage","serous drainage,","sero-sangineous drainage","***"}. A total of *** {blank single:19197::"staples","sutures"} were noted to be present. Per MD, @M@ @LNAME@ is okay to have them removed.

    Orders received, allergies reviewed. @M@ @LNAME@ was positioned for comfort and to facilitate the procedure. Wound cleansed with {blank multiple:19196::"alcohol","betadine","chlorhexdine","normal saline","***"}, and a total of *** {blank single:19197::"staples","sutures"} were removed {With/Without:20273} difficulty {blank single:19197::"after the patient was premedicated with ***","without the use of analgesic"}. @M@ @LNAME@ tolerated the procedure {DESC; WELL/FAIRLY WELL/POORLY:18703}.

    The wound was cleansed again as before. The edges of the incision were swabbed with tincture of benzoin and steri-strips applied over incision to reinforce it. The incision {blank single:19197::"was otherwise left open to air","was then covered with ***"}.

    Dr {blank single:19197::"Brigman","Eward","***"} informed @M@ @LNAME@ when @HE@ can shower. @M@ @LNAME@ was instructed that steri-strips are in place to reinforce incision while it continues to heal, and that once they fall off they do not need to be replaced.

    @M@ @LNAME@ was asked to contact us with any questions or concerns.

    John Hillson RN
    Hillsborough NC

  • 5.  RE: Nursing documentation in Radiation Oncology

    Posted 05-21-2019 18:07
    We use Epic EMR in our facility and have been able to have assessment tools customized to suit our department. The providers request certain information be obtained from the patients at consult such as do they have a pacemaker, have they had Radiation or chemotherapy in the past etc. Vitals are obtained at every office visit and once a week during treatment and prn. Nursing documents medical, surgical, and social history. We review meds and allergies . Much of the is stream lined by the EMR .

    Janet Messina