Download Treatment Record Summary Template

Gynaecology Surgery
Dear Patient Name
TREATMENT SUMMARY
You have now completed your initial treatment for cancer. This Treatment Summary provides a summary of
your diagnosis, treatment and on-going management plan. It includes information on the symptoms you should
be aware of, and who to contact. Your GP will also receive a copy of this summary.
Diagnosis:
Date of Diagnosis:
Summary of Treatment and relevant dates:
Staging
FIGO Stage:
PS ECOG
Grade:
Treatment Aim:
Operation details:
Date:
Pathology results
Significant events during / after procedure:
Possible treatment toxicities and / or late effects:
Hormone replacement therapy (delete as
nec):
Y/N
Genetic testing:
Yes
Not applicable
Pending
Result:
Clinical Trial:
Possible early side effects
Pain and discomfort
Vaginal discharge + bleeding for up to 6 weeks
Infection: wound site/lower respiratory tract infection
Blood clots in leg/lung (Pulmonary Embolism/ Deep Vein Thrombosis)
Prescription Charge exemption arranged
Yes/No
Possible future effects of treatment
Anti-coagulation advice
Early menopause
Leg swelling (Lymphoedema)
Urinary frequency / urgency / incontinence
Bowel frequency incontinence
Sexual Consequences (Vaginal Narrowing, dryness, reduced libido)
Other:
Advise entry onto primary care palliative or
supportive care register
Yes / No
DS 1500 application completed
Yes/No
Alert Symptoms that require referral back to specialist team:
Persistent pain in the abdomen/ pelvis
Persistent vaginal bleeding/ discharge
Abdominal bloating or swelling
Others:
Persistent breathlessness
Persistent cough
Constantly feeling tired
Unintentional weight loss (greater than 5%)
Loss of appetite
Lower limb swelling
Secondary Care Ongoing Management Plan: (tests, appointments etc)
Year
1
2
3
4
Onward referrals made: (delete as nec)
Benefits Advisor
Menopause clinic
Occupational Therapy
Physiotherapy
Counselling
Psychosexual counsellor
Health and Wellness Clinic/ Event
Social Service
Incontinence team
Spiritual support
Lymphoedema team
Support Group
Community Palliative Care Team
Genetics referral
Other
5
Clinic:
Blood tests
Scans:
Other:
Recommended GP actions in addition to GP Cancer Care Review (e.g. ongoing medication, osteoporosis and cardiac
screening) (delete as necessary)
Please remove patient from cervical screening program
Please prescribe HRT as outlined above
Bone density monitoring – Frequency?
Please be alert to possibility of new symptoms as a consequence of treatment as outlined above
Please be alert to possibility of new symptoms of cancer as outlined above
Additional information including issues relating to lifestyle and support needs(delete as necessary):
Smoking cessation advice given
Diet and weight management
Physical activity
Alcohol intake
Sunscreen advice
Health and Wellbeing Event Date:
Summary of information given to the patient about their cancer and future progress:
Contact details for referrals or specialist advice:
Consultant:
Clinical Nurse Specialist:
Out of hours:
Completing Doctor:
Signature:
Date:
Supporting Documents that may help – Please delete this section before giving to the patient
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Fatigue Prompt Tool
(http://www.londoncanceralliance.nhs.uk/media/122127/lca-hna-fatigue-prompt-sheet-january-2016.pdf)
Pain Prompt Tool
(http://www.londoncanceralliance.nhs.uk/media/122133/lca-hna-pain-prompt-sheet-january-2016.pdf)
Weight Gain prompt tool
(http://www.londoncanceralliance.nhs.uk/media/118608/lca-hna-weight-gain-prompt-sheet-january2016-v3.pdf)
Sexual Consequences for Women (http://www.londoncanceralliance.nhs.uk/media/118602/lca-hna-sexconsequences-women-prompt-sheet-january-2016.pdf)
Lymphoedema Guidelines
(http://www.londoncanceralliance.nhs.uk/media/100466/lca-lymphoedema-referral-and-managementguidelines-june-2015.pdf)
GP READ CODES FOR COMMON CANCERS (For GP Use only). Other codes available if required.
(Note: System codes are case sensitive so always ensure codes are transcribed exactly as below)
System 1
Diagnosis:
Lung Malignant Tumour
Carcinoma of Prostate
Malignant tumour of rectum
Bowel Intestine
Large Bowel
Female Malignant Neoplasia
Male Malignant Neoplasia
Histology/Staging/Grade:
Histology Abnormal
Tumour grade
Dukes/Gleason tumour stage
Recurrent tumour
Local Tumour Spread
Mets from 1°
Treatment
Palliative Radiotherapy
Curative Radiotherapy
Chemotherapy
Radiotherapy
Treatment Aim:
Curative procedure
Palliative procedure
Treatment toxicities/late effects:
Osteoporotic #
Osteoporosis
Infection
Ongoing Management Plan
Follow up arranged (<1yr)
Follow up arranged (>1yr)
No FU
Referral PRN
Referrals made to other services:
District Nurse
Social Worker
Nurse Specialist
SALT
Actions required by the GP
Tumour marker monitoring
PSA
Osteoporosis monitoring
Referral for specialist opinion
Advised to apply for free prescriptions
Cancer Care Review
Palliative Care Review
Medication:
New medication started by specialist
Medication changed by specialist
Advice to GP to start medication
Advice to GP to stop medication
Information to patient:
DS1500 form claim
Benefits counselling
Cancer information offered
Cancer diagnosis discussed
Aware of diagnosis
Unaware of prognosis
Carer aware of diagnosis
Miscellaneous:
On GSF palliative care framework
GP OOH service notified
Carers details
National Cancer Survivorship Initiative
December 2010
(5 digit
codes)
XaOKG
X78Y6
XE1vW
X78gK
X78gN
B34..
B35..
4K14.
X7A6m
XaOLF
XaOR3
X7818
XaFr.
5149.
XalpH
x71bL
Xa851
Xallm
XaiL3
Xa1TO
XaELC
Xa9ua
8H8..
XaL..
8HA1.
8HAZ.
XaBsn
XaBsr
XaAgq
XaBT6
Xalqg
Xalqh
XalSd
Xalst
9D05
Xalyc
XalG1
XEOhn
8B316
XaKbF
XaJC2
All other systems
Version 3 five byte
codes
(October 2010
release)
Diagnosis
Malignant neoplasm of bronchus or lung
Malignant neoplasm of prostate
Malignant neoplasm of Rectum
Malignant neoplasm of Colon
Malignant neoplasm of female breast
Malignant neoplasm of male breast
B22z.
B46..
B141.
B13..
B34..
B35..
Histology/Staging/Grade:
Histology Abnormal
Tumour staging
Gleason grading of prostate Ca
Recurrence of tumour
4K14.
4M…
4M0..
4M6..
Metastatic NOS
Treatment
Radiotherapy tumour palliation
Radiotherapy
Chemotherapy
BB13.
5149.
7M371
8BAD.
Treatment Aim:
Curative treatment
Palliative treatment
8BJ0.
8BJ1.
At risk of osteoporosis
Osteoporosis
1409.
N330.
Ongoing Management Plan
Follow up arranged
8H8..
No follow up arranged
8HA..
Referrals made to other services:
Refer to District Nurse
Refer to Social Worker
8H72.
8H75.
Actions required by the GP
Tumour marker monitoring
PSA
Osteoporosis monitoring
8A9..
43Z2.
66a..
Entitled to free prescription
Cancer Care Review
Palliative Care Plan Review
Medication:
Medication given
Medication changed
6616.
8BAV.
8CM3.
8BC2.
8B316
Information to patient:
DS1500 completed
Benefits counselling
Cancer information offered
Cancer diagnosis discussed
9EB5.
6743.
677H.
8CL0.
XaJv2
Xaltp
Miscellaneous:
On GSF Palliative Care Framework
GP OOH service notified
8CM1.
9e0..
9180.
Carer details
9180.
XaCDx
6743.
XalmL
XalpL
XaQly
XaVzE
XaVzA