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Policy
Number:
Title: Survivorship Program
Regulation
Reference: COC OMH Accreditation Standard 4.4
Effective
Date:
Purpose:
XXXXX Survivorship program’s goal is to maximize the quality of life of survivors and their caregivers.
National Cancer Institute states “in cancer, survivorship focuses on the health and life of a person with
cancer post treatment until the end of life.”
Policy:
Personnel affected: Physicians, Advance Practitioners, Navigators, Nurses, and Medical Assistants.
Oncology patients should be contacted within 90 days of completing treatment or entering long term
maintenance treatment to schedule a Survivorship visit. The program addresses long term needs,
side effects, and outlines strategies for management.
Procedure:
1. When an oncology patient completes treatment, a referral should be completed to the
survivorship clinic.
i. Referral order is completed in the EMR
ii. Referral is then sent to survivorship team
2. Survivorship team will review the medical record, complete treatment summary document, and
survivorship care plan.
3. Treatment summary and care plan will include the following:
 Diagnosis
 Date of and age at diagnosis
 Cancer Stage and histology
 List of all providers involved in cancer diagnosis/treatment
 Treatments administered
 Surveillance schedule
 Health promotion strategies/health goals/patient needs
4. A clinician will visit with the patient at a scheduled appointment to review the treatment summary,
care plan and surveillance schedule. Together they will focus on patient needs/desires and
collaborate on goals for health promotion.
5. Referrals to appropriate support staff to assist in meeting needs and health goals.
6. Patient will be provided a copy of each document.
7. Copies of all documents will be forwarded to PCP and all providers involved in cancer
diagnosis/treatment.
Responsibility and Approval Authority:
This policy shall be reviewed by the appropriate committees, managers and staff to whom it is relevant, approved by the
Executive Committee of the Board, with final signatory authority of the Medical Director.
Version Number:
Original Approval Date:
Reviewed Date:
Prepared by:
Approved by:
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