| Sumario: | Significance & Background: As oncology patients receive more care in the outpatient setting, education on side effects and the documentation of nursing interventions to treat those side effects is key to their care. Purpose: Patient education didn't exist within our electronic medical record (EHR). The ambulatory nursing team wanted to consolidate education and nursing documentation and make it consistent across the teams. The goal was to save nursing time and reinforce patient education. Interventions: The Clinic nursing team met and prioritized symptoms that needed standard documentation using the ONS Nursing Telephone Triage book and chemoed.com. Each patient complaint includes nursing interventions for the patient complaint, when to call again, and when to visit urgent care or emergency room (ER). Documentation can be used during triage calls or in clinic. Documentation was created for: * Nausea * Vomiting * Constipation * Diarrhea * Neutropenic precautions * Bleeding precautions * Fatigue * Arthralgia/myalgia * Mouth sores * Cold sensitivity * Neuropathy Once created, RNs leading the project brought back documentation to share with the team for discussion, changes and final approval. When the documentation was finalized the team taught peers how to document and then checked each nurse off on appropriate use. Results: This project brought consistency to nursing documentation and gave the nurses the ability to document patient issues based on their complaints. Nurses state they spend less time charting since moving to this process. They also report It is easy to find prior data in the record to see what worked for the patient previously. Charting is consistent across staff and clinics. The documentation is also good reinforcement of education for patients on the side effects they are experiencing and how to manage them. Discussion: Optimizing EHR documentation has saved time for nursing staff at our organization. It has also helped us reinforce patient education at multiple points during the patient's journey. Having nursing interventions ready to use and documented in the chart has helped the nurses work at top of license and be able to create a case if they need to speak to an APP or MD about next steps to continue treatment. Audits are currently being completed for patients that are admitted or go to the ER with nausea, vomiting, diarrhea, and dehydration. The goal is to decrease admissions and ER visits by continuing to enhance nursing education and documentation.
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