Chemotherapy/Radiation Communication Record

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. 

2. Information to Include: 

• Resident Information: 

• Resident Name: ________________________________ 

• Date: ________________________________________ 

• Facility Information: 

• Skilled Nursing Facility: __________________________ 

• Unit: _________________________________________ 

• Phone Number: ________________________________ 

3. Oncology/Chemotherapy/Radiation Center Information: 

• Center Name: __________________________________ 

• Vital Signs: 

• BP: _______________ 

• Temp: _______________ 

• Pulse: _______________ 

• Resp: _______________ 

• Radiation Site(s): ______________________________ 

4. 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: __________________________________ 

5. 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: ________________________________ 

6. Follow-Up: 

• Date of Next Treatment: __________________________________ 

• Provider Signature: ______________________________________ 

• Printed Name: __________________________________________ 

• Date: __________________________________________________ 

7. 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