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Templates Used to Document Chemotherapy

Templates Used to Document Chemotherapy

SAN DIEGO—The use of electronic chemotherapy documentation templates, developed by the nursing staff of Marshfield Clinic Cancer Care,
Marshfield, Wisconsin, has led to improved efficiency and readability, and
allows all health care providers immediate access to clinically relevant
information.

Sherry Wiedow, RN, OCN, an oncology nurse clinician at Marshfield Clinic
Cancer Care, described the templates at the 26th Annual Conference of the
Oncology Nursing Society (ONS abstract 66). Darlene Pawlik Plank, RN, MSN,
AOCN, coauthored the abstract.

The electronic documentation system was developed by the Clinic’s
Information Systems Department, she said, while the templates were developed by
the oncology nurse clinicians.

The templates follow set criteria for content and format, and are created
for both common and complex chemotherapy regimens. They include title of the
regimen, intravenous access, antiemetics/premedications, chemotherapy, fluids,
assessment of IV site at the completion of therapy, and patient education.
There are blank fields for medication dose and duration of therapy. Medications
are documented using generic names.

Ms. Wiedow said that nurse clinicians electronically select one of 60
templates now available and fill in the drug doses and therapy duration. If the
patient care does not follow the template, the nurse clinician may revise the
template online to reflect the care given. Once completed, the electronic note
is uploaded, electronically signed, and immediately made available to all
clinicians.

"Previously, we were writing notes, on a paper chart that had to be
called up; you physically had to get your hands on it," she said.
"When we went to an electronic system, all notes were available
immediately for uploading. We could get the most recent information on a
patient and how he or she had been treated."

An issue that came up in the process of creating the templates was the need
to standardize the entire practice. "There are 11 nurses working in the
Oncology Department. We thought we were all doing things the same way but found
out we each were doing things a little differently," Ms. Wiedow said.
"To truly document the care we provide, we needed to take a look at our
practice and standardize what we were doing based on the literature and
recommendations."

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