Sample Follow-up Letter That Can Be Sent to Nursing Home
or Convalescent Hospital
Date of Letter: 1/1/02
Care Convalescent Home
1234 Any Street
Anytown, XX 99999
A follow-up is conducted annually by the Cancer Registry
of all patients treated at Anytown Medical Center with a diagnosis
of cancer is conducted by the Cancer Registry. Our records
show that the patient listed below was transferred to your
facility. To complete our records, we would appreciate information
regarding this patient. Any questions may be directed to the
Cancer Registry at (999) 555-9999.
Sincerely,
John Doe, M.D.
Chair, Cancer Committee
Re: Doe, Jane Mary Last
Follow-up Date:
Date of Birth: 1/1/50 Accession
Number/Sequence:
Diagnosis: Breast CA
Patient Status:
1. Alive--Still in your facility: _______ Yes ________ No
If answer is no -- date transferred:
___________________________
-- where transferred: __________________________
| A. |
Status of Neoplasm: |
|
B. |
Quality of Survival: |
|
| |
No evidence of cancer |
________ |
|
Normal activity |
________ |
| |
With evidence of cancer |
________ |
|
Symptomatic and |
|
| |
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|
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ambulatory |
________ |
| |
Cancer status unknown |
________ |
|
Ambulatory more than |
|
| |
|
|
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50%, occasionally |
|
| |
|
|
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needs assistance |
________ |
| |
New areas of recurrence |
|
|
|
|
| |
and/or metastasis |
________ |
|
Ambulatory less than |
|
| |
|
|
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50%, nursing care needed |
________ |
| |
Site: ________________ |
|
|
|
|
| |
|
|
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Bedridden, may require hospitalization |
|
| |
|
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| 2. |
Expired -- Place: __________________ |
Date: ___________________ |
| |
Cause of death: __________________ |
Autopsy? ______ Yes ______ No |
Comments: _____________________________________________________
Patient's Attending Physician: _____________________________________
Address: _______________________________________________________
|
