A plan for patient follow-up that links the treatments a patient has received from an oncologist and the needs of the patient after intensive cancer treatments have been completed. With about 10 million cancer survivors in the U.S., and that number rising, survivors are living longer and receiving more fragmented care. A follow-up care plan helps communicate to the patient and his or her future health care providers details of cancer staging, treatment, and disease surveillance that may otherwise be misunderstood or neglected. According to the Institute of Medicine, such a plan should include the following elements: 1. a clear, concisely written statement of the patient's diagnosis, the methods used in treatment (such as what specific chemotherapeutic drugs and what doses of radiation), and the expected or potential effects of that treatment; 2. detailed information about the need for specific follow-up services and a timetable specifying when such services should be delivered; 3. information about secondary disease prevention (including the detection of cancer recurrence and the need for monitoring for secondary cancers); 4. information about the availability of support services and agencies in the patient's community; 5. information for the patient about legal protections after diagnosis, including employment and insurance.
Survivor care plans are often drawn up and given to patients by oncologists or advanced practice nurses. They should address concerns about nutrition, physical activity, exercise, and mobility; elimination; cognition and perception; pain and discomfort; sleep, and rest; self-perception; relationships with spouse, parents, children, other family members, and friends; and sexuality and reproductive issues.