CHEMOTHERAPY TREATMENT RECORD Consultant.. Name DOB.. Hospital Number. PRIMARY DIAGNOSIS MDT discussion date.. Consent for treatment obtained Yes / No Consent Form signed Yes / No (If no do not give Chemotherapy and refer to Oncologist/Haematologist/Clinical Assistant) Chemotherapy Treatment Regime.... Treatment plan cycles Entered into trial. Number. Planned start date any previous treatments given? ( if so please state)... Treatment considerations (ie scalp cooling) Patient offered summary of consultation Yes / No Key worker.. Disease/ treatment info pack given to patient Patient sign Practitioner sign. Record of treatment given (for full details see treatment sheets) Date Cycle Treat/Defer (if defer state no of days) Dose modification (Yes/ No) Permanent drug modification (If so please state what) Supplementary drugs Final course completed Yes / No If no state why: (please circle) Toxicity / sub-optimal response/ Recurrence / Other Doctor s signature. Document prepared by Kate Lambert Senior Sister Chemotherapy, 1 additional information from Andrew Lyons Ward
Patients Name Unit No Date Date Cycle CT Bone marrow Trial bloods Paraprotein Clinic review Communication with Patient and Relatives Does the patient wish their prognosis to be discussed with themselves Yes / No Does the patient wish their prognosis to be discussed with their relatives Yes / No (If no state name and contact).. Permission obtained for future discussions of care/prognosis with relatives Yes / No May discuss future care details with.. before /following discussion with patient NB: Recheck this information on each reassessment visit for each cycle to ensure the information is unchanged. All disciplines using this document please enter signature and initials below: Print Name Signature Initials Discipline ABBREVIATIONS PEP Principles for Effective Practice Document VIP score Visual Infusion Phlebitis PEP 0022 The administration of, and continuing care of patients receiving cytotoxic therapy as inpatients and outpatients. PEP 0003 Peripheral Intravenous Cannulation REFERENCES Department of Health (1997), The Caldicott Committee Report, NHS Executive. Department of Health (2003), Confidentiality:NHS Code of Practice, Version 3.0 Department of Health (2004), The Manual of Cancer Services. Peer Review Measures. Accessible via www.doh.gov.uk/www cquins.nhs.uk Document prepared by Kate Lambert Senior Sister Chemotherapy, 2 additional information from Andrew Lyons Ward
Patients Name Unit No Date Next of kin... Contact No.. 1 st contact in Emergency. Contact No.. 2 nd contact in emergency. Contact No... GP (check this with patient.. Contact Number (if known) Address.... Past Medical/Surgical history....... Current Medication... Allergies Baseline observations BP Pulse. Temp.. Weight Pain assessment score: Ask the patient which word best describes their pain? (please circle). No pain 0 Mild pain 1 Moderate pain 2 Severe pain 3 Please state: Site. duration severity Action taken by nurse (if required).... * Inform doctor to review if applicable or contact Specialist Palliative Care Services for pain assessment & advice Lifestyle: (please circle) Breathless at rest / exertion / lying flat / no problems? Smokes Yes / No Do you wish to stop smoking Yes / No Do you want to be referred to the smoking cessation team? Date referred Alcohol Yes / No Units per week.. Exercise Yes / No Do you take recreational drugs? Yes / No Nutrition: Record nutritional risk score. (refer to dietician as required and document such referral within assessment). Elimination: (circle) Incontinence - urinary / faeces / doubly / catheter / no problems Catheterised urethral / suprapubic Bowel problems constipation / diarrhoea / stoma / no problems Yes / No Ex smoker, date stopped. Action taken by nurse (if required).... Document prepared by Kate Lambert Senior Sister Chemotherapy, 3 additional information from Andrew Lyons Ward
Refer to Dr for appropriate anti-motility drugs, aperients if required. Patients Name Unit No Date Communication ( circle) Eye sight: Visually Impaired / Registered Blind / Glasses or contact lenses used for reading / distance No Problems Hearing problems: yes / no If yes please state. Oral assessment: (circle) Condition of mouth: Healthy / sore / any cavities / dentures Action taken by nurse (if required).... Outcome of of initial initial Vascular Access assessment needs Mobility assessment Walks unaided Yes / No Walks with aids (Please state).. Needs assistance to mobilise/move (Please state equipment needed). Spiritual assessment ( circle) Does the patient require help in meeting their spiritual/ religious/cultural needs? Yes / No If yes please state... Do they want to speak to the chaplaincy service? Yes / No Psychological assessment What concerns or worries do you have? (State in patients own words where possible) The assessment nurse should observe and comment on signs of anxiety / depression and comment on how well the patient is coping with their diagnosis and treatment plan. Document any referrals on referral sheet. NB: Patients can be referred for Psychology Support through the weekly Specialist Palliative Multidisciplinary Team Meeting. Document prepared by Kate Lambert Senior Sister Chemotherapy, 4 additional information from Andrew Lyons Ward
Discuss any other issues regarding sexuality, body image or any other specific concerns/ worries please specify. Do you have problems with sleeping? yes / no Do you take night sedation or require any sleeping medication yes / no (Refer to Oncologist/Haematologist/Clinical Assistant if required) Social Assessment (State what support (informal/formal) the patient will have during their treatment (ie informal support from partner, mother/father, friend, or formal support such as that provided by social work, other professional organisations/agencies, self help groups). Who will be the patient s main carer?.. Are there any special requirements that the main carer cannot provide. (If yes please state).. Action taken by nurse (if required).. Accommodation: (circle) Does the patient live in a house / maisonette / bungalow / flat / sheltered accommodation / residential home / nursing home / other please specify.. Does the patient sleep: upstairs / downstairs Are the toilet facilities: upstairs / downstairs Are there any environmental or safety issues? Yes / no Does the patient have any pets? Is the patient employed / unemployed / retired / other please state. Does the patient have any financial worries? Yes/no If yes a referral should be made here to social worker/relevant professional Does the patient want to see a social worker for any specific issues? If so please state. Referrals Orthotics (wig) Clinical Nurse Specialist Macmillan Nurses Dietician Social Worker District Nurse Physiotherapist Occupational therapist Any others: please specify Signature/ Date referred Date seen/signature Document prepared by Kate Lambert Senior Sister Chemotherapy, 5 additional information from Andrew Lyons Ward
Initial Assessment completed by: Sign Date.. Document prepared by Kate Lambert Senior Sister Chemotherapy, 6 additional information from Andrew Lyons Ward