Documentation of care in an oncology outpatient setting

Finding time to perform thorough documentation in a busy oncology outpatient setting is an increasingly difficult task. This article describes the development of a new documentation system designed for an oncology outpatient unit. The system consists of a set of documentation tools that are specific for the type of patient visit, an initial assessment form, and guidelines for using the forms. The system was developed to reduce the amount of nursing time spent on documentation and to improve the quality of the documentation. Evaluation of the system indicated that the forms decreased charting time by 50%. Suggestions for modifying and revising the tools are included. This system could be adapted for use in any ambulatory oncology setting.