Consistent documentation of toxicity symptoms improves outcomes

Devising a comprehensive electronic medical record (EMR)-generated nursing assessment, including toxicity grading and decision support, provides consistent communication and documentation for management of symptoms in ambulatory oncology. This allows for more effective interventions and improved outcomes, results of a project conducted at the Smilow Cancer Hospital at Yale-New Haven, New Haven, Connecticut, presented during the Oncology Nursing Society 36th Annual Congress has found.

According to Joan Moore, APRN, MSN, AOCN®, ACNS-BC, comprehensive nursing assessment is essential to developing interventions that can prevent, minimize, or treat cancer therapy sequelae. Increasingly, clinical decision support systems are being used. These systems are most successful when they are integrated into the workflow at the time of decision-making and are imbedded in the nursing assessment without requiring nurse activation. In addition, comprehensive assessment can be improved when a systematic approach is used that includes decision support and prompts assessment of all symptoms using common language in toxicity assessment.

To improve symptom management documentation, a comprehensive ambulatory flowsheet in the EMR was developed that included integrated decision support and National Cancer Institute (NCI) toxicity criteria terminology, she said.

Creating an EMR nursing assessment flowsheet provided a systems review along with assessment of the most common physical and psychosocial symptoms. The NCI Common Terminology for Adverse Events Version 4.0 was built into assessment responses, allowing a consistent language to be used to describe symptoms of toxicity in patients undergoing chemotherapy.

The flowsheet prompts toxicity evaluation for and documentation of fatigue, nausea and vomiting, diarrhea and constipation, mucositis, neuropathies-y, and rash, as well as depression and anxiety, and sexual dysfunction, the latter of which are sometimes overlooked. Moore and colleagues audited 185 ambulatory visit flowsheets between May and October 2010 to document how toxicity was evaluated. Of 665 abnormal findings, toxicity grading criteria were demonstrated for all abnormal findings; 25% were symptoms graded 2 or higher. Documentation of type and extent of rash (5% of all abnormal findings) was found to be improved. Symptoms of depression, anxiety, and sexuality comprised 28% of easily identified, abnormal findings, which previously were imbedded in nursing notes.

She noted that as more institutions enhance documentation systems with the use of EMRs, the flowsheet could be easily replicated in these institutions to enhance communication among health care professionals, with the goal of preventing, minimizing, and/or promptly treating symptoms associated with cancer therapy.
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