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[Facility Name]

SURVIVORSHIP CARE PLAN (Surgical, Medical, and Radiation Oncology)


Section I TREATMENT SUMMARY

Patient Name: Date of Birth:

Primary Care Physician: Ph: Fax:

Diagnosis: Stage: New Recurrence Intent: Curative Control

Cancer Treatment Providers:


MED ONC Ph:
MED ONC APN/RN Ph:
RAD ONC Ph:
RAD ONC APN/RN Ph:
SURGEON Ph:
OTHER Ph:
SOCIAL WORKER Ph:
DIETITIAN Ph:

Surgical Procedure: Date:


Surgical Procedure: Date:

Clinical Trial: No or Yes If Yes, Name?


Radiation Therapy:
Technique Used:
Site(s) Treated:
Dose(s) Delivered: Total
Date Initiated:
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 individuals 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:

B. Proposed Follow-up Care:


Physical Exam: Frequency: Provider to Contact: Phone:
Example: Physical Exam years 1 3 Every 3 months


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.

[Facility Name]

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 individuals 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
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: Provider: Phone:


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

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)

SURVIVORSHIP CARE PLAN

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 individuals 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
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 physicians 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
patients 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 individuals 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