Rutgers Cancer Institute of New Jersey
195 Little Albany Street
New Brunswick, NJ 08903-2681
Documentation of patient care allows healthcare professionals to understand the care being provided, the effectiveness of interventions and any clinical problems that may need further resolution. Without well-structured documentation, it can be difficult for the healthcare team to improve the quality of care. CINJ Director of Oncology Nursing Services Janet Gordils-Perez, MA, APN-C, AOCNP, led a recent effort to enhance the documentation process of patient care at CINJ.
A comprehensive review of all current nursing documentation was completed. Forms were condensed and simplified into a user-friendly checklist format that prompts 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 Putting Evidence into Practice® resources for evidence-based interventions and evaluation. CINJ nurses piloted the documentation tool and revisions were made after feedback was obtained.
Informal observations from nurses who utilized the new tool suggest increased satisfaction with recording data in this manner. Formal evaluations with audits are planned to ensure documentation is accurate, clear and complete and that standards of oncology nursing practice are met. Impact on patient outcomes also will be explored.
"It is critical for nurses to assume responsibility for the standards of their practice as well as documentation. They are accountable for providing evidence-based, quality nursing care and documenting these services. By providing a uniform documentation tool, we can ensure quality nursing care by using the strongest level of evidence on which to base nursing practice interventions. It also ensures that regulatory and institutional standards are being met," says Gordils-Perez. She notes the electronic documentation tool can be adapted for use by all outpatient care nurses nationally in order to benchmark quality measures and ensure streamlined, evidence-based documentation with the goal of improving patient outcomes that are directly affected by nursing care.
At the conference, Gordils-Perez also was recognized as an ONS Foundation Institutes of Learning Conference Scholarship recipient.
About The Cancer Institute of New Jersey
The Cancer Institute of New Jersey (www.cinj.org) is the state's first and only National Cancer Institute-designated Comprehensive Cancer Center dedicated to improving the detection, treatment and care of patients with cancer, and serving as an education resource for cancer prevention. CINJ’s physician-scientists engage in translational research, transforming their laboratory discoveries into clinical practice, quite literally bringing research to life. To make a tax-deductible gift to support CINJ, call 732-235-8614 or visit www.cinjfoundation.org. CINJ is a Center of Excellence of the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School. Follow us on Facebook at www.facebook.com/TheCINJ.
The CINJ Network is comprised of hospitals throughout the state and provides the highest quality cancer care and rapid dissemination of important discoveries into the community. Flagship Hospital: Robert Wood Johnson University Hospital. System Partner: Meridian Health (Jersey Shore University Medical Center, Ocean Medical Center, Riverview Medical Center, Southern Ocean Medical Center, and Bayshore Community Hospital). Major Clinical Research Affiliate Hospitals: Carol G. Simon Cancer Center at Morristown Medical Center, Carol G. Simon Cancer Center at Overlook Medical Center, and Cooper University Hospital. Affiliate Hospitals: CentraState Healthcare System, JFK Medical Center, Robert Wood Johnson University Hospital Hamilton (CINJ Hamilton), Somerset Medical Center, The University Hospital/UMDNJ-New Jersey Medical School*, and University Medical Center at Princeton. *Academic Affiliate