[Facility Name]

CANCER TREATMENT SUMMARY

Radiation Oncology

Patient Name: Date of Birth:

Primary Care Physician: Ph: Fax:

Diagnosis: Stage: New or Recurrence

Treatment Start Date: End Date: Intent: Curative or Control

Next Oncology Follow-up Appoint. Date: Provider Name:

Cancer Treatment Providers:

MED ONC / Ph: / Fax:
MED ONC APN/RN / Ph: / Fax:
RAD ONC / Ph: / Fax:
RAD ONC APN/RN / Ph: / Fax:
Surgeon / Ph: / Fax:
Ph: / Fax:
Surgical Procedure: / Date:
Surgical Procedure: / Date:

Clinical Trial: Yes or No If Yes, Name?

Radiation Therapy:

Technique Used:
Site(s) Treated:
Dose(s) Delivered: / Total
Date Initiated:
Date Completed:
Ongoing Side Effects/Complications:

Referrals: Social Worker Spiritual Care Tobacco Cessation Counseling Palliative Care

From Boyajian, R. (2009). Survivorship treatment summary and care plan: Tools to address patient safety issues? Clinical Journal of Oncology Nursing, 13(5), 584-586. doi:10.1188/09.CJON.584-586

Nutrition Rehabilitative Services Counseling Other

Advanced Directives: Yes or No

Comments/Other:

Summary Completed By: Date:

Physician/PA/APRN Signature: Date:

Why a Cancer Treatment Summary?

The purposebehind a cancer treatment summary is threefold:

  • to present your medical information in a clear concise manner,
  • to allow you to share your cancer treatment information with your physician and other medical providers, which in turn opens up the lines of communication, and
  • to help reduce the likelihood of having an error affect your treatment.

Being diagnosed with cancer is an overwhelming experience. You receive a lot of information during your treatment, and you may have difficulty retaining all this information. A treatment summary can assist you with remembering details about your treatment.

What About a Care Plan?

You may also discuss a care plan with your doctor. A care plan may contain everything your treatment summary contains, but it is alsoan overview of what issues may develop from your cancer treatment. A care plan can help you alleviate many fears you may have surrounding your cancer diagnosis and treatment, and can help you feel safer about your health.

Some of the important information that should be included in a treatment summary and/or care plan includes:

  • the cancer diagnosis,
  • specific information about your treatment,
  • referrals to outside assistance,
  • information about how to live a healthy lifestyle, specifically pertaining to the cancer diagnosis,
  • information about side-effects from treatment, and
  • information about what future screenings you require, and when you should have these screenings.

From Boyajian, R. (2009). Survivorship treatment summary and care plan: Tools to address patient safety issues? Clinical Journal of Oncology Nursing, 13(5), 584-586. doi:10.1188/09.CJON.584-586