Immunotherapy Toxicities: A New Electronic Documentation Template to Improve Patient Care

Elizabeth Reimschissel, MSN, RN, CN; Buenagracia Dela Cruz, BSN, MBA, RN, OCN®; Melissa Gonzalez, BSN, RN, OCN®; Joaquin Buitrago, MS, RN, OCN®; Cary Goodman, BBA, MIS; and Patricia A. Johnston, DNP, RN, OCN®, NEA-BC
CJON
10.1188/17.CJON.s2.41-44

Description

Background: Emerging immunotherapies are associated with numerous toxicities. Although traditional health records allow nurses to document system-based assessments, few offer immunotherapy-based documentation templates to assess and grade toxicities.

Objectives: The aim of this article is to present the development of a standardized template for documenting genetically modified cellular product–related toxicities in an electronic health record (EHR).

Methods: Through interprofessional collaboration, a documentation template for genetically modified cellular product–related toxicities was developed in an EHR, allowing for standardized documentation, data reporting, and tracking of immune-related toxicities.

Findings: The documentation template has enhanced the quality and safety of practice at the authors' institution and provides a framework for other nursing units when initiating immunotherapy care.

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