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Hospital Outpatient Infusion Documentation

  • 1.  Hospital Outpatient Infusion Documentation

    Posted 14 days ago
    ​​I work at a large community hospital with Joint Commission accreditation.  We are in the process of expanding our hospital outpatient infusion center from 27 chairs to 51 chairs.  We use Cerner as our EHR.  We are required to do an intake on every patient with every visit, even if the patient is coming in daily or just for an injection.  The intake includes a history (general info, infectious disease info, privacy info, meds by history, allergies, and advanced directives info), a Morse assessment, a violence risk predictor, and a modified physical assessment.  Documenting the intake can take 10-15 minutes so nurses are spending more time doing the intake than providing some of the treatments.  The documentation also does not address physical issues common with chemotherapy treatments so this has to be entered separately.  I would like to eliminate unnecessary documentation, but I'm having a difficult time finding out exactly what is mandatory according to the JC.  I'm interested in hearing what other hospital outpatient infusion centers document with each patient visit.  I appreciate any input that can be provided.

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    Marie Hooper, MSN, RN, OCN
    Director, Cancer Services
    Aultman Hospital
    Canton, Ohio
    marie.hooper@aultman.com
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  • 2.  RE: Hospital Outpatient Infusion Documentation

    Posted 13 days ago
    Hi Marie
    I used to work at a similar outpt setting. We used Epic to document. are medical assistants would do the vitals on the patients as well do a mini screening for depression and do the med req.
    Once the patient was brought back to the room it would be the nurse's job to do a modified physical assessment. It would cover the general signs and symptoms that you would see in a patient that just has cancer  , currently receiving treatment or is post treatments. It would include the diet intake it would include depression anxiety. But we would not go over the medical history or the past medical history unless it deemed necessary. The doctors or residents would cover that in their visit. So in order to avoid redundant questions we would leave that out.

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    Christina Lopez RN
    Registered Nurse II
    Texas Oncology
    Lewisville TX
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  • 3.  RE: Hospital Outpatient Infusion Documentation

    Posted 9 days ago
    Thanks for the response.  Your charting sounds much more reasonable to me.​

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    Marie Hooper, MSN, RN, OCN
    Director, Cancer Services
    Aultman Hospital
    Canton, Ohio
    marie.hooper@aultman.com
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  • 4.  RE: Hospital Outpatient Infusion Documentation

    Posted 9 days ago
    Jeepers! How many patients do you each take!? Yeah cerner is pretty cr@p for oncology. You click and click and if your ever look at a printed saved form it looks like you did next to nothing. For us every patient when new gets an admission assessment. Beyond that every day every patient gets vitals, iv line before and after, height weight bsa, fall risk, symptoms, distress, ecog, pain, suicide risk, Med rec, mar, education assessment, closing note. Most of it is point and click and we push documenting by exception. Focus on expected side effects versus actual, doc at bedside or other issues.

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    Jeremiah Davis, BSN, RN, OCN, CRNI, BLS, ACLS
    Registered Nurse Charge Adult Infusion Services
    University Medical Center of El Paso
    El Paso, Texas
    9154128802
    Jvdavisrn@yahoo.com
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  • 5.  RE: Hospital Outpatient Infusion Documentation

    Posted 3 days ago
    You're lucky!  I've had a few meetings about this documentation and it looks like we will not be making any changes at this point.​

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    Marie Hooper, MSN, RN, OCN
    Director, Cancer Services
    Aultman Hospital
    Canton, Ohio
    marie.hooper@aultman.com
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  • 6.  RE: Hospital Outpatient Infusion Documentation

    Posted 3 days ago
    ​Can I ask what fall assessment tool people are using?  Currently we are using hester davis but I'm not sure of its validity in the outpatient setting.  Any experiences you all have with an assessment tool would be appreciated.  Thanks!

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    Rebecca Corkery RN BSN
    nurse clinician
    Mercy St Louis Hospital
    Saint Louis MO
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  • 7.  RE: Hospital Outpatient Infusion Documentation

    Posted 2 days ago
    Hi Marie
    I feel your pain as we also use Cerner but are migrating to EPIC in 9 months.
    Your facility is requiring you to over-document, and it makes absolutely no sense. We are a hospital-based outpatient Infusion department (NCI designated comprehensive cancer center) and have gone through many TJC and Department of Health and FACT inspections--and our documentation has never been questioned. As with other posters, we do an assessment and document requirements (e.g., pain) but your facility is adding more than required--unless that's in your state department of health regulations.

    Seth

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    Seth Eisenberg RN ASN OCN BMTCN
    PROFESSIONAL PRACTICE COORDINATOR, INFUSION SERVIC
    Seattle Cancer Care Alliance
    Federal Way WA
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  • 8.  RE: Hospital Outpatient Infusion Documentation

    Posted 2 days ago
    Seth,

    Do you complete any type of history form or medication review?  I would appreciate any feedback.  None of the documentation is required by our regulatory bodies.  Risk and infection control is mandating much of the documentation.  I'm trying to provide them with supporting evidence that this is not done elsewhere.  Thanks for your response.​

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    Marie Hooper, MSN, RN, OCN
    Director, Cancer Services
    Aultman Hospital
    Canton, Ohio
    marie.hooper@aultman.com
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  • 9.  RE: Hospital Outpatient Infusion Documentation

    Posted 2 days ago
    We use the Morse Fall Risk Assessment.  It's okay, but it doesn't always place people in the right risk category​.

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    Marie Hooper, MSN, RN, OCN
    Director, Cancer Services
    Aultman Hospital
    Canton, Ohio
    marie.hooper@aultman.com
    ------------------------------