Michigan Oncology Quality Consortium (MOQC) – Making ...
Date: ______________
Patient Initials: __________________ MRN: _________________ Oral Chemo ID#: ____________
← Patient consent documented in the medical record – includes:
o intent of treatment (curative or palliative care)
o expected response to treatment
o treatment benefits and harms
o information on quality of life
o patient’s likely experience with treatment
o who will take care of the patient’s care – cancer care team
← Physician initiation note including:
o diagnosis (including specific tissue information, relevant biomarkers and stage)
o prognosis
o treatment goals
o initial plan for treatment and proposed duration (including specific chemotherapy drug names and schedule as well as surgery and XRT if applicable)
o treatment benefits and harms, including common and rare toxicities and short- and long-term effects and how to manage
o referrals, based on initial plan and treatment goals (e.g. navigator, pharmacist)
o Plan for addressing patient’s psychosocial health needs, financial management and other (should this go here or via first nurse visit?)
← Patient has documented advanced care plan with a designated patient advocate in the medical record
← Patient has advanced directives in the medical record
← Estimated total and out-of-pocket costs documented by MA or other in medical record (or done via pharmacy teaching session?)
← Patient referred to oral chemotherapy teaching via electronic message within medical record – Pharmacist:
o Completes intake form and Oral chemo ID# recorded
o Counsels on possible toxicities and self-management strategies
o Provides F/U plan and symptom and adherence assessment plan; documents discussion with patient in medical record
o Patient registered on patient portal
o Start date recorded (will this be here or during first nurse visit?)
← Patient seen by nurse on days of oncology appointment
o Completes oral chemo assessment tool
o RN summarizes and develops plan – discusses with patient and documented in medical record
o Start date recorded on first f/u visit (will this be here or during pharm oral teach visit?)
← Patient identifiers removed from patient assessment (Initials and MRN) – faxed to MOQC with oral chemo ID# included
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Patient Intake for Oral Chemotherapy
Oral Chemotherapy Checklist
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