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Chemotherapy/Radiation Communication Record

Nursing Administrative Manual

Chemotherapy/Radiation Communication Record 

Policy 
To ensure seamless communication and continuity of care for residents undergoing chemotherapy or radiation treatment, a standardized communication record will be used. This record will facilitate the transfer of pertinent information between the Skilled Nursing Facility (SNF) and the Oncology/Chemotherapy/Radiation Center. 

Procedure 

  1. Completion of Communication Record: 

  • A Chemotherapy/Radiation Communication Record must be completed for each resident undergoing treatment. This record will be filled out during each oncology/chemotherapy/radiation appointment. 

  1. Information to Include: 

  • Resident Information: 

  • Resident Name: ________________________________ 

  • Date: ________________________________________ 

  • Facility Information: 

  • Skilled Nursing Facility: __________________________ 

  • Unit: _________________________________________ 

  • Phone Number: ________________________________ 

  1. Oncology/Chemotherapy/Radiation Center Information: 

  • Center Name: __________________________________ 

  • Vital Signs: 

  • BP: _______________ 

  • Temp: _______________ 

  • Pulse: _______________ 

  • Resp: _______________ 

  • Radiation Site(s): ______________________________ 

  1. Communication of Condition: 

  • Document any changes in condition from the last appointment/treatment (e.g., pain, redness at sites, change in mental status, behavior, medication changes, appetite, falls, etc.). Attach a copy of any recent labs. 

  • Communication from: __________________________________ 

  1. Recommendations from Oncology/Radiation: 

  • Treatment done/Medication given: ___________________________ 

  • Expected Side Effects from Chemotherapy Medication: ___________ 

  • Monitoring that should be done by __________________ in relation to Chemotherapy/Radiation: __________________________________ 

  • Recommendations/Orders: ________________________________ 

  1. Follow-Up: 

  • Date of Next Treatment: __________________________________ 

  • Provider Signature: ______________________________________ 

  • Printed Name: __________________________________________ 

  • Date: __________________________________________________ 

  1. Review and Filing: 

  • Reviewed By: __________________________________________ 

  • Signature: _____________________________________________ 

  • Date: _________________________________________________ 

  • A copy of the resident’s current Medication Administration Record (MAR), Face Sheet, and Treatment Administration Record (TAR) (if applicable) should accompany this form. 

Documentation and Review: 

  • The completed Chemotherapy/Radiation Communication Record must be reviewed and signed by the nursing supervisor upon return from the oncology/chemotherapy/radiation appointment. 

  • All communication records are to be filed in the resident’s medical record. 

References: 

  • Centers for Medicare & Medicaid Services (CMS), State Operations Manual (SOM) 

  • Requirements of Participation for Nursing Homes, CMS 

Tags
Chemotherapy/Radiation Communication Record
Chemotherapy Communication
Radiation Treatment
Nursing Home Policies
CMS compliance
SOM
Resident Care Coordination
Section C. Nursing Administration Manual
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