(Facility Name) SURVIVORSHIP CARE PLAN (Surgical, Medical, and Radiation Oncology) Section I - Treatment Summary

[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
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]

Section II FOLLOW-UP CARE PLAN
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

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.


(Facility Name) SURVIVORSHIP CARE PLAN (Surgical, Medical, and Radiation Oncology) Section I - Treatment Summary

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[Facility Name]

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

Patient Name: Date of Birth:

Primary Care Physician: Ph: Fax:

Diagnosis: Stage: New Recurrence Intent: Curative Control

Cancer Treatment Providers:

Surgical Procedure: Date:

Clinical Trial: No or Yes If Yes, Name?

On-going Side Effects:

New Hampshire Comprehensive Cancer Collaboration 2011 www.nhcancerplan.org

Section II FOLLOW-UP CARE PLAN

Patient Name: Date of Birth:

A. Things to Watch for & Report:

B. Proposed Follow-up Care:

New Hampshire Comprehensive Cancer Collaboration 2011 www.nhcancerplan.org

Patient Name: Date of Birth:

Description: Provider: Phone:

Summary Completed By: Date:

Physician/PA/APRN Signature: Date:

Summary Completed By: Date:

Physician/PA/APRN Signature: Date:

SURVIVORSHIP CARE PLAN

New Hampshire Comprehensive Cancer Collaboration 2011 www.nhcancerplan.org

PRODUCED BY: NH COMPREHENSIVE CANCER COLLABORATION

Section I Treatment Summary

Section II - Follow-Up Care Plan

A. Symptoms to Watch for & Report

B. Proposed Follow-Up Care

New Hampshire Comprehensive Cancer Collaboration 2011 www.nhcancerplan.org

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