Documentation pertaining to a patient’s treatment is an important aspect of safety. Documentation includes the patients’ healthcare record (paper and electronic) and relevant information used to inform treatment decisions. As facilities move towards using electronic information management systems for cancer therapy and patient records it is important that access to documentation is not restricted.
The primary patient healthcare record and all documentation applicable to the prescribing, dispensing and administration of cancer treatment should be readily accessible to all staff at the point of care and be up-to-date.
The documentation in healthcare records must provide an accurate description of episodes of care and patient contact with healthcare personnel. Local policies should be in place to ensure the use of standardised documentation to communicate all information pertaining to a patient’s treatment, e.g. toxicities, changes in treatment and discontinuation of treatment.
Clinical handover is also an integral part of clinical care and documentation. Documentation of handover has the benefit of minimising error and failures in clinical handover which have been identified as a major preventable cause of patient harm.
Document management and accessibility of patient heathcare records may be governed by local and state policy.
All documentation must be legible and organised in a standardised format.
Important and variable patient data that may be used to inform treatment decisions and clinical verification of therapy should be made available to all staff in a timely, easy to read manner (e.g. weight, laboratory results). Where electronic systems are used to obtain and store information, procedures should be in place for storage and access of information.
Local policies should be in place to ensure that when a patient's care is transferred to another setting, all relevant documentation pertaining to that patient’s treatment is transmitted accurately and patient confidentiality is protected (Neuss et al, 2017; Goldspiel et al, 2015).
A standardised clinical handover process and documentation for patients receiving cancer therapy should be adopted (Australian Commission on Safety and Quality in Health Care, 2012).
Protocols, procedures and other documentation templates that are stored electronically should be in a read-only format to avoid unapproved or undetectable alterations that could lead to errors. Access to original clinical protocols and templates should be restricted to named, authorised staff.
Printing copies of procedures and protocols that are available electronically should be minimised. This can lead to out-of-date information being accessed and incorrect procedures being utilised. A useful statement to add as a footnote is: All printed copies of this document are considered uncontrolled copies. Printed copies are only valid for the day printed.
The printing of patient relevant documentation that is stored electronically should be minimised unless essential to inform a patient healthcare record or to provide information to the patient.
- Goldspiel B, Hoffman JM, Griffith NL, Goodin S, DeChristoforo R, Montello CM, et al. ASHP guidelines on preventing medication errors with chemotherapy and biotherapy. Am J Health Syst Pharm 2015 Apr 15;72(8):e6-e35 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25825193.
- Carrington C, Stone L, Koczwara B, Searle C, Siderov J, Stevenson B, et al. The Clinical Oncological Society of Australia (COSA) guidelines for the safe prescribing, dispensing and administration of cancer chemotherapy. Asia Pac J Clin Oncol 2010 Sep;6(3):220-37 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20887505.
- Neuss MN, Gilmore TR, Belderson KM, Billett AL, Conti-Kalchik T, Harvet BE, et al. 2016 Updated American Society of Clinical Oncology/Oncology Nursing Society Chemotherapy Administration Safety Standards, Including Standards for Pediatric Oncology. Oncol Nurs Forum 2017 Jan 6;44(1):31-43 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/28067033.
- Australian Commission on Safety and Quality in Health Care. National Safety and Quality Health Service (NSQHS) Standard 6: Clinical Handover.; 2012 [cited 2017 May] Available from: https://safetyandquality.gov.au/wp-content/uploads/2012/01/NSQHS-Standards-Fact-Sheet-Standard-6.pdf.