Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
[Facility Name] SURVIVORSHIP CARE PLAN (Surgical, Medical, and Radiation Oncology) Section I – TREATMENT SUMMARY Patient Name: Date of Birth: Primary Care Physician: Diagnosis: Ph: Stage: Fax: New Recurrence Intent: Curative Control Cancer Treatment Providers: MED ONC MED ONC APN/RN RAD ONC RAD ONC APN/RN SURGEON OTHER SOCIAL WORKER DIETITIAN Ph: Ph: Ph: Ph: Ph: Ph: Ph: Ph: Surgical Procedure: Surgical Procedure: Date: Date: Clinical Trial: No or Yes Radiation Therapy: Technique Used: Site(s) Treated: Dose(s) Delivered: Date Initiated: If Yes, Name? Total Date Completed Chemotherapy/Biotherapy/Treatment Plan: (Ex: Adriamycin/Cytoxan q 2wks x 4 doses) Agent Route Dose/Total Dose Start Date End Date Comments/Complications: On-going Side Effects: On-going Treatment: New Hampshire Comprehensive Cancer Collaboration – 2011 – www.nhcancerplan.org Important caution: this is a summary document whose purpose is to review the highlights of the cancer treatment and proposed follow-up care for this patient. This does not replace information available in the medical record, a complete medical history provided by the patient, examination and diagnostic information, or educational materials that describe strategies for coping with cancer and cancer therapies in detail. Both medical science and an individual’s health care needs change, and therefore this document is current only as of the date of preparation. This summary document does not prescribe or recommend any particular medical treatment or care for cancer or any other disease and does not substitute for the independent medical judgment of the treating professional 03/05/13 [Facility Name] Section II – FOLLOW-UP CARE PLAN Patient Name: Date of Birth: A. Things to Watch for & Report: Surgery: Radiation Therapy: Medical Oncology: Physical Exam: Example: Physical Exam years 1 – 3 B. Proposed Follow-up Care: Frequency: Provider to Contact: Every 3 months Phone: Imaging: Lab: C. General Guidelines: Consult with your Primary Care Physician (PCP) regarding appropriate screening tests and frequency for you as indicated by your age, health, and personal/family cancer history. New Hampshire Comprehensive Cancer Collaboration – 2011 – www.nhcancerplan.org Important caution: this is a summary document whose purpose is to review the highlights of the cancer treatment and proposed follow-up care for this patient. This does not replace information available in the medical record, a complete medical history provided by the patient, examination and diagnostic information, or educational materials that describe strategies for coping with cancer and cancer therapies in detail. Both medical science and an individual’s health care needs change, and therefore this document is current only as of the date of preparation. This summary document does not prescribe or recommend any particular medical treatment or care for cancer or any other disease and does not substitute for the independent medical judgment of the treating professional 03/05/13 [Facility Name] Section II – FOLLOW-UP CARE PLAN Patient Name: Date of Birth: D. Other Services: Referrals to other providers may become necessary depending on individual patient needs/goals. This section provides an opportunity to identify with the patient what additional services/programs may be beneficial to their survivorship. Description: Financial Counseling Genetic Counseling Integrative Medicine Nutrition Palliative Care Rehabilitation Services(PT/OT/SLP) Psychosocial Support One-on-one counseling Support group Tobacco cessation Exercise program Other Provider: Phone: Radiation Oncology: Summary Completed By: Date: (Print name) Physician/PA/APRN Signature: Date: (Signature) Medical Oncology: Summary Completed By: Date: (Print name) Physician/PA/APRN Signature: Date: (Signature) New Hampshire Comprehensive Cancer Collaboration – 2011 – www.nhcancerplan.org Important caution: this is a summary document whose purpose is to review the highlights of the cancer treatment and proposed follow-up care for this patient. This does not replace information available in the medical record, a complete medical history provided by the patient, examination and diagnostic information, or educational materials that describe strategies for coping with cancer and cancer therapies in detail. Both medical science and an individual’s health care needs change, and therefore this document is current only as of the date of preparation. This summary document does not prescribe or recommend any particular medical treatment or care for cancer or any other disease and does not substitute for the independent medical judgment of the treating professional 03/05/13 SURVIVORSHIP CARE PLAN SUGGESTED GUIDELINES FOR USE PRODUCED BY: NH COMPREHENSIVE CANCER COLLABORATION This Survivorship Care Plan (SCP) template is intended for use by cancer care providers to create a document that will facilitate on-going cancer care for patients completing active treatment. The template, which is a modifiable word document, is divided into two sections, a treatment summary and a follow-up care plan. The following suggested guidelines have been developed to assist providers in utilizing the tool to meet American College of Surgeons (ACS) CoC standard which requires accredited programs to ensure SCPs are available for patients completing treatment for a cancer diagnosis. Section I – Treatment Summary The data provided in this section is essentially self-explanatory. Cancer care provider contact information, specific treatment(s) (chemotherapy/biotherapy, surgery, and radiation therapy) delivered and notation of on-going treatment. Examples: Comments/Complications – Chemotherapy dosage reduced due to adverse side effects. On-Going Side Effects – Neuropathy On-Going Treatment – Hormone Therapy Section II - Follow-Up Care Plan A. Symptoms to Watch for & Report This section should mirror the attending physician’s specific end of treatment instructions verbally delivered to the patient regarding possible short term and long term side effects of respective treatments. Example - For a patient with breast cancer: arm swelling, bone pain, new lumps, persistent headaches. B. Proposed Follow-Up Care This section should provide patients with a description of a recommended schedule of post treatment periodic testing and examinations as well as who should perform/order said exams/tests. Example: Exam/Test Frequency Provider to Contact Phone Physical Exam years 1-3 Every 3 Months Dr. Smith 603-880-2071 C. General Guidelines This section should highlight specific screening tests/activities that the PCP physician recommends as indicated by the patient’s age, health, and personal/family cancer history. Example- mammogram annually D. Other Services Referrals to other providers may become necessary depending on individual patient needs/goals. This section provides an opportunity to identify with the patient what additional services/programs may be beneficial to their survivorship. New Hampshire Comprehensive Cancer Collaboration – 2011 – www.nhcancerplan.org Important caution: this is a summary document whose purpose is to review the highlights of the cancer treatment and proposed follow-up care for this patient. This does not replace information available in the medical record, a complete medical history provided by the patient, examination and diagnostic information, or educational materials that describe strategies for coping with cancer and cancer therapies in detail. Both medical science and an individual’s health care needs change, and therefore this document is current only as of the date of preparation. This summary document does not prescribe or recommend any particular medical treatment or care for cancer or any other disease and does not substitute for the independent medical judgment of the treating professional 03/05/13