| 1. Identification |
Name, hospital record, date of birth, age, gender, nationality, naturalness, provenance, educational background, occupation, ethnicity, marital status if you have children (how old and their age), who you live with, telephone number and name of the responsible for reporting collected data |
| 2. Information regarding diseases and treatment |
Medical diagnosis; chemotherapy protocol; cycle, day and interval of chemotherapy; purpose of treatment (cure, palliation, concomitant with radiotherapy); complaints; awareness about disease/treatment; previous treatment of the disease and adverse reactions, as well as measures and effectiveness of the adopted behaviors; family history of cancer; personal history that represents risk for complications throughout the treatment; surgical history; and medicines of habitual use (prescribed by medical team or self-medication) |
| 3. Health habbits |
Social history (smoking, alcoholism and use of illicit drugs) and allergies, health control (periodicity of routine exams, dental evaluation, body care and hand hygiene) and habits related to psychobiological and psychosocial needs (feeding, hydration, urinary elimination and intestinal, sexual and reproductive function, locomotion and mobility, sleep pattern, physical activity, recreation, and leisure and housing) |
| 4. Physical examination |
Weight, height, Body Mass Index, body surface, blood pressure, heart and respiratory rate, oxygen saturation, temperature, vascular access, presence of devices, oral cavity evaluation, skin integrity, pain, pressure ulcer, and field for the description of other changes observed during the physical examination |
| 5. Psychosocial aspects |
Communication, work, support, family support/friends, religion/belief, how the person perceives themselves before illness and treatment, self-esteem, changes in Daily Life Activities, expectation regarding treatment and nursing consultation, interest in participating of treatment |
| 6. Laboratory and imaging examinations |
Hemoglobin, hematocrit, leukocytes, neutrophils, platelets, renal function (creatinine and urea), liver enzymes, previous echocardiogram, pulmonary function evaluation and open field to record unrelated and relevant exams according to chemotherapy protocol |
| 7. Nursing Diagnoses |
Open field for description by the professional, according to the problems raised |
| 8. Nursing Interventions |
Open field for description by the professional, according to the existing evidence in the literature or institutional protocols |
| 9. Referrals |
Constituted by some areas (Physiotherapy, Psychology, Nutrition, Speech Therapy, Social Work and Stomatherapy) in a checklist format and an option called "other" with space for specification of other specialties, besides contemplating a field for the description of the justification of the request |
| 10. Extravasation |
Puncture place, material used in the procedure, extravasated medication, time of installation and extravasation, signs and symptoms presented, actions taken, referral to the vascular surgeon, extravasation evaluation based on the Common Terminology Criteria for Adverse Events scale, version 4.0 |
