Development of nursing documentation for use in the outpatient oncology setting

In response to the particular demands upon patients and nursing staff in the outpatient setting, and the identification of a need for nursing orientated documentation, a new nursing documentation system has been developed and implemented within an oncology day unit. The documentation is used by the nursing team engaged in the care of patients receiving outpatient chemotherapy treatment. The system consists of documents for the initial and ongoing assessment, planning, implementation and evaluation of nursing care. These include pretreatment patient self-assessment forms, flowsheets for the documentation of chemotherapy treatment and administration and a record for information and teaching given to patients and significant others. Referrals to other services and health care professionals are also documented. This tool is designed to ensure a high standard of nursing intervention and maximize quality of life in this group of patients. An audit is planned to evaluate the effectiveness of this tool and highlight any areas requiring improvement or modification. There are also plans to further develop this system for use in the inpatient and community setting.