The Value of New Fields in the Medical Record for Quality Improvement

Quality in healthcare delivery is important for the safety and experience of patients with cancer. Effective documentation is an integral component of quality improvment, and accurate documentation can be affected by prompts in the medical record, potentially improving quality of services.

The Contemporary Oncology Team (COT) is a Greek private oncology practice that participated in the American Society of Clinical Oncology's (ASCO's) Quality in Oncology Practice Initiative (QOPI). Between 2014 and 2019, COT implemented changes in its paper patient medical record, in order to improve quality of care and documentation. Fields regarding pain, emotional well-being and psychosocial assessment, discussions with the patient and consent about treatment and disease, medication details and cumulative dose, treatment goals, side-effect grading, pregnancy screening, treatment adherence and anticipated duration were added. In this report, we present the association of these improvements with COT performance in QOPI.

Pain and emotional well-being assessment and documentation were significantly improved by the development of a structured patient follow-up form. In contrast, the assessment of fertility issues, tobacco use, and the documentation of treatment plan and intent did not present a drastic change, because COT performance was already above QOPI average.

A thorough reform of COT paper medical record according to QOPI standards improved QOPI scores, but more importantly effected a shift in the team's culture to safer and more standardized quality based care.