Download ReACT Treatment Summary (Generic)

Reintegration After Cancer Treatment (ReACT)
Generic Treatment Summary
Personal Details
Care Team
Name
CHI
Address
Ethnicity
Mobile
Email
Lead Consultant
Nurse Specialist
Principal Hospital
GP Name & address
Sex
Code
GP Telephone
Cancer Summary
Diagnosis
Primary Site
Date of diagnosis
Treatment protocol
Disease Status
Remission
Active
Palliative
Active Problems
Stage
Metastatic Sites
Start of treatment
End of treatment
Date of 1st Follow Up
Medication
Aftercare plan
Cancer surveillance
Year 1
Year 2
Year 3
Year 4
Year 5
Toxicity monitoring
Psychosocial status
HNA outcome
Living with
Education/employment
AHP support
Performance Status
Other
Code
Code
Code
Psychosocial Support
Information given
Referrals made
GP Alerts and Recommendations
Completed by
Name:
Signature:
Patient CHI Number:
Job Title:
Checked by
Designation:
Date:
Name:
Signature:
Key Worker:
Email:
Phone:
Designation:
Date:
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Treatment History
Clinical Trial
Intervention trial available
Trial name
On trial
Yes / decline / not offered / not eligible
Other trial
Chemotherapy (delete if no chemotherapy received)
Summary:
Total dose
Total dose
Total dose
Total dose
Total dose
Total dose
Transplant (delete if no transplant received)
Type
Yes / No
Conditioning regimen
Comments
Radiotherapy (delete if no radiotherapy received)
Dates
Site(s)
Comments
Total dose
Organs at risk
Fractions
Surgery (delete if no surgery required)
Date
Pathology
Comments
Procedure
Other Treatment
Complications during treatment
End of Treatment Investigations
Investigation
Height/weight/BMI
Blood Pressure
MRI / CT
GFR
Echo
Other
Date
Result
Re-immunisation
Date
Vaccine
Comment
Date
Vaccine
Fertility
Pubertal stage
Risk of infertility
Low/Medium/High
Fertility preservation
Offered / declined / not offered
Fertility preservation details
Checklist
ReACT summary completed
HNA completed
Aftercare guidance given
Date
Fertility discussed
Date of storage
Contraception
Checklist
Referrals made
Date
Next clinic appointment
Transition Plan
Other
Distribution list
Patient
GP
Other
Key worker
CNS
Other
Patient Consent:
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Signature:
Date: Click here to enter a date.
Patient CHI Number:
Job Title:
Key Worker:
Email:
Phone:
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