New fields in the patient record: A tool or a nuisance?

235 Background: The Contemporary Oncology Team was the first practice in Greece to participate in the Quality in Oncology Practice Initiative (QOPI). As a result, several corrective measures were designed and implemented to improve the quality of the services provided to patients.

METHODS: The plan-do-check-act approach was used to implement changes, primarily in the follow up form, over a period of 18 months. Several improvement opportunities were identified. 1.) A numerical scale for pain intensity quantification became a required field. 2.) Emotional well-being fields were added so the patient's state could be documented by providers. 3.) Fertility assessment and counseling was added as a required field in the patient record. For this report we evaluated retrospectively the effect of these changes on our QOPI scores.

RESULTS: Contemporary Oncology Team QOPI scores after the implementation of the new forms have shown increased compliance, compared to QOPI aggregate scores for all participating US practices, in the areas related to the changes made. Specifically, pain assessment documentation improved from -54.56% to +9.96%. The use of a numerical tool proved invaluable to comparing pain intensity between different visits. Emotional well-being documentation improved from -42.55% to +18.26%. Fertility assessment documentation has not improved but this finding could be due to a decrease in patient chart sample size. Providers seemed to adapt quickly and without difficulty.

CONCLUSIONS: Developing new fields in the patient record is an evolving process because it requires provider education and acquaintance with the new method of documentation. However, in this retrospective analysis it proved to be an effective method to improve provider compliance with assessment of pain and emotional well-being, and it is likely to be useful in other areas in need of improved documentation.