NEW ORLEANS—Use of an electronic evidence-based documentation tool can help improve patient outcomes, according to research presented at the Oncology Nursing Society (ONS) 37th Annual Congress.

Providing quality cancer care that is in compliance with the highest standards and clearly documenting it is a challenge faced by nurses. Documentation provides a means for understanding the care given, effectiveness of interventions, and clinical problems needing resolution. Without well-structured documentation, it is difficult to assess care delivered by the health care team.

At The Cancer Institute of New Jersey, New Brunswick, NJ, an NCI-designated Comprehensive Cancer Center, nurses identified the need to improve their documentation process of patient care.

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The purpose of developing an electronic evidence-based nursing documentation tool was to ensure quality oncology nursing care by using the strongest level of evidence on which to base nursing practice interventions as well as meet regulatory and institutional standards. To ensure this, the cancer center’s goal was to integrate all the ONS PEP® resources into the documentation tool to help guide practice.

After review of all current nursing documentation, forms were condensed and simplified into a user-friendly checklist format that prompted the nurse to complete an in-depth assessment using the Common Terminology Criteria for Adverse Events as a measurement tool, the NANDA-based nursing diagnosis, and the ONS PEP resources for evidence-based interventions and evaluation. The documentation tool was piloted, nursing feedback was obtained, and appropriate revision was made.

Nurses have expressed increased satisfaction with the new electronic documentation tool. To improve continuity of care, a partner hospital’s oncology outpatient area has implemented the tool as well.

Additional feedback from the partner hospital’s staff as well as other practitioners (MD/NP) was reviewed and revisions were made. Formal evaluations are planned with audits to ensure documentation is accurate, clear, and complete and that standards of oncology nursing practice are met. They will also evaluate how changing documentation has impacted nursing-sensitive patient outcomes.

It is critical for nurses to assume responsibility for the standards of their practice as well as documentation. Nurses are accountable for providing evidence-based, quality nursing care and documenting these services.

“This electronic documentation tool may be adapted for use by all ambulatory care nurses nationally to benchmark quality measures and ensure streamlined, evidence-based documentation with the goal of improving nursing sensitive patient outcomes,” the authors concluded.