Cancer survivorship EHR note template: Guide and prompt for primary care cancer

survivorship visit

1) Cancer Treatment History and Survivorship Care

Diagnosis a:

Stage (If applies)

Laterality, receptors/important descriptors

Date and age at diagnosis:

Treatment

Surgery b:

Chemotherapy c:

Adjuvant endocrine therapy d:

Radiation e:

Targeted biologic therapy:

Immunotherapy:

Bone marrow transplant:

Current symptoms and management f:

Late effects g:

Genetic counseling and testing h:

Reproductive health i:

Surveillance: includes imaging, assessment of bone density, laboratory tests, and others j:

Follow-up plan with cancer care team, primary care, and other specialistsk:

2) Health Maintenance

Vaccinesl: Tdap, flu, pneumococcal, inactivated zosterm

Pap testm: Last , due

Mammogramm: Last , due

Colonoscopym: Last , due

DEXAm: Last , due

Lung cancer screeningm:

Dental check:

Screening labsm:

Exercise and nutrition:

3) Supportive Caren

Mood, anxiety, fear of cancer recurrenceo:

Coping and supportp:

Sexual healthq:

Financial health, employment:

4) Resourcesr

Patient Education: Cancer.net , American Cancer Society

Meditation, Relaxation: Calm, Headspace

Psychosocial support: Cancer Support Community, CANCERcare, National Coalition for Cancer
Survivorship Toolbox

Nutrition guidance: Stanford Introduction to Food and Health

Local support groups:s

a
By asking the patient to describe the method of diagnosis (screen detected or symptom based)
the PCP engages in a personal conversation and assesses the patient’s experience with cancer
care
b, Age at diagnosis
b
Surgery details include only basic information including date
c
Full names of chemotherapy drugs are listed to remove ambiguity for patient and other
healthcare providers around abbreviations and completion date
d
Applies to patients with hormonally driven diseases (prostate and breast cancer) and should
include the drug type, start date of therapy, and intended duration of treatment
e
Completion date, field i.e. left breast or pelvic, and dose (if known)
f
Refers to side effects of cancer treatment (also known as long term effects)
g
Risk of subsequent complications due to prior exposures to cancer treatments
h
Document genetic testing date and result and any additional secondary cancer screening per
result. If no genetic testing, take personal and family cancer history, then make appropriate
referrals for genetic counseling and testing if needed.
i
Explore interest in family building
j
Serves to clarify what tests are needed or not needed (i.e. patient with bilateral mastectomies
does not require annual mammograms and this is stated), the frequency, and name of the
ordering clinician
k
Consider additional vaccinations if bone marrow transplant history, surgical or functional
asplenia
l
States the names of the clinicians involved in the patient’s care and follow-up schedule,
including name of PCP if different from clinician conducting this visit
m
As indicated
n
Psychosocial issues
o
Assessment for psychological distress, anxiety/depression and fear of cancer recurrence;
assess satisfaction and/or difficulties with sexual health
p
Identify primary caretaker or support, how survivorship has impacted relationship
q
Body image
r
Not a comprehensive list
s
Familiarity with local resources is encouraged