ONCOCHART Nursing Documentation
Through an agreement with the Oncology Nursing Society (ONS), the ONCOCHART Nursing Documentation forms are based on the ONS Radiation Therapy documentation tools. BMSI Partners, Inc. is pleased to incorporate what nurses around the country have come to view as the “Gold Standard” for radiation therapy nursing documentation into ONCOCHART.
Proper documentation is an important and time-consuming issue for nurses. ONCOCHART solves these problems with the development of nurse’s documentation forms. There are pre-defined questions and answers programmed into ONCOCHART that allows the nurse to document information quickly and easily. In the event one of the pre-defined answers does not fit the situation, the nurse can either enter another of his/her choosing or dictate directly into the microphone attached to their computer using any compatible voice dictation software. Answers to questions considered Prognostic Factors may be viewed in a graph format and followed over time.
Examples of graphable Prognostic Factors are, Blood Pressure, Oxygen Saturation, Lymphedema Measurements, Hemoglobin, Mucositis and Karnofsky Performance Scale.Portions of the documentation are designed to populate the corresponding physician note. This eliminates the need for double entry of patient information by the nurse. Completed nursing documentation can be retained electronically (and viewable through the patient’s Electronic Medical Record or EMR) or printed for inclusion in the patient’s chart.
Nursing Documentation with ONCOCHART
- Initial Nurse Assessment
- Vital Signs
- Past Medical/Family History
- Social History
- Review of Systems
Radiation Therapy Patient Care Record
- Treatment Related Information
- Patient Assessment
Patient Teaching and Instructions
- Procedures
- Treatment
- Referral
- Prevention
