Treatment Record Summary â User Guide - National Cancer ...

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GP READ CODES – CANCER (For GP Use only)System 1 5 digit codes All other systems 4 digit codesDiagnosis:DiagnosisLung Malignant Tumour XaOKG Lung Cancer .B222Carcinoma of Prostate X78Y6 Prostate Cancer .B46Bowel Intestine X78gK Malignant neoplasm of Rectum .B14Large Bowel X78gN Malignant neoplasm of Colon .B13Female Malignant Neoplasia B34 Cancer female breast .B34Male Malignant NeoplasiaB35Histology/Staging/Grade:Histology Abnormal4K14Tumour grade X7A6m Tumour staging .4MDukes/Gleason tumour stage XaOLF Gleason .4MORecurrent tumour XaOR3 Recurrence of tumour .4M6Local Tumour SpreadX7818Mets from 1° XaFr Carcinoma metastases .BB13TreatmentPalliative Radiotherapy 5149 Tumour palliation .5149Curative Radiotherapy XalpH Radiotherapy .7M371Chemotherapy x71bL Chemotherapy .8BADRadiotherapyXa851Treatment Aim:Curative procedure Xallm Curative procedure .8BJOPalliative procedure XaiL3 Palliative procedure .8BJ1Treatment toxicities/late effects:Osteoporotic #Xa1TOOsteoporosis XaELC Osteoporosis .1409InfectionXa9uaOngoing Management PlanFollow up arranged (1yr)XaL.No FU 8HA1 No follow up arranged .8HAReferral PRN8HAZReferrals made to other services:District NurseXaBsnSocial WorkerXaBsrNurse SpecialistXaAgqSALTXaBT6Actions required by the GPTumour marker monitoringXalqgPSAXalqhOsteoporosis monitoring XalSd Osteoporosis monitoring .66AReferral for specialist opinionXalstAdvised to apply for free prescriptions 9D05 Entitled to free prescriptions .6616rMedication:New medication started by specialist XEOhn Medication given .8BC2Medication changed by specialist 8B316Advice to GP to start medication XaKbFAdvice to GP to stop medication XaJC2Information to patient:DS1500 form claim XaCDx DS1500 .9eb5Benefits counselling 6743Cancer information offeredXalmL
Treatment Summary User Guide Appendix 2Field Rationale for inclusion EssentialorDesirableDiagnosisImportant for the GP and patient to know type of cancer and location of Ecancer and the likely source of secondary recurrence.Organ Staging/local or distant spread Information about staging and spread provides insight into prognosis and D(Grade)Date of DiagnosisSummary of Treatment and relevantdatesTreatment AimPossible treatment toxicities and or lateeffects of treatmentrisk of recurrenceTo understand length of time patient has known diagnosis and time periodbetween referral from primary care and diagnosis to learn where delayscan be minimised in future. Important data to monitor treatment outcomesin relation to survivorship. Helps plan date of GP Cancer Care Review.To understand the range and order of modality treatment, understand thelikely sequence of treatment effects. Essential to inform future treatmentchoice if further disease occurs. Important information for patients wishingto take out insurance or a mortgage.To understand whether treatment intended is curative, palliative or forsymptom relief as this will help GPs to understand aims of treatment, referback to secondary care or other services appropriately. Also help GPs toanticipate future care needs.Patients undergoing cancer treatments may be more prone to toxicity andlate effects of treatment such as osteoporosis or heart disease. Inclusionof risks in this summary triggers the entering of the patient onto routine GPsurveillance (QOF related). Signs and symptoms addressed earlier mayimprove quality of life and treatment outcomes from side effects or lateconsequences of treatment.Inclusion of suggested or preferred treatment associated with toxicities andlate effects can be initiated without referral back to the specialist.Raises awareness of common late effects and reduces delays to furtherinvestigation and treatment. This may also impact on survival rates assymptoms are picked up soonerDEEE
Page 8 and 9: Advise entry onto palliative or sup
Page 10 and 11: Treatment Summary Example Appendix

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