Patient Treatment Planner

30 Pages·2011·1.96 MB·English

Patient Treatment Planner
Treating You With Dignity
Treating You With Dignity™
Welcome to Kimmel Cancer Center at Jefferson
When you or a loved one have been diagnosed with cancer, you want the best doctors, the latest
treatment, and state-of-the-art technology. That is exactly what you’ll find at the Kimmel Cancer
Center at Jefferson. Our nationally recognized cancer specialists combine the latest treatment with
compassionate care and support.
The Kimmel Cancer Center at Jefferson is a cancer center designated by the National Cancer Institute. This
recognition for excellence in cancer research and treatment allows patients access to the very latest in care.
Our cancer specialists are some of the nation’s most outstanding medical experts. Many of our oncologists
have been featured in “Best Doctors in America” and contribute to leading scientific journals such as
Cancer and Cell.
At the Kimmel Cancer Center at Jefferson, we succeed in helping you fight cancer by working together with
your medical team, family and friends. Our commitment to collaborative cancer care, our concern for you
and your family and our reputation for excellence will give you the confidence and peace of mind you need
in your fight against cancer.
Our focus is on you – helping you through your diagnosis and helping you to understand your disease
and treatment options, and then providing the best care available for your recovery.
Partnering with You and Your Doctor to Achieve Optimum Results
We work closely with your primary care doctor and the specialists involved in your treatment. You and
your doctors will make decisions about your specific treatment plan. Together we’ll carefully consider
the type and stage of the cancer, your age and general health, the risks and benefits of various treatment
options, and your personal preferences for treatment.
With new treatment strategies and early diagnosis, many patients with cancer can be
cured. At the Kimmel Cancer Center, you’ll find the latest and most progressive
treatment programs and equipment available. Our approach to cancer is
multidisciplinary, which means we form a team that involves the many medical
specialties required for comprehensive care. We are both your partner and guide
on the road to recovery.
Cancer can affect many aspects of your life. That’s why the Kimmel Cancer Center
at Jefferson works together with you and your family, helping you to meet your
physical and emotional needs during this difficult time. We are committed to treating
each person as an individual, with the understanding that you are more than a patient
with cancer.
We realize that you may have many worries and concerns at this time, and
we feel strongly that your emotional health is as important as your physical
health. Consequently, we have established an active cancer advocacy and
support program that can provide many benefits for you and your family.
From state-of-the-art diagnosis and treatment to compassionate care, support
and follow-up, the Kimmel Cancer Center at Jefferson is your partner on the
road to recovery.
Richard G. Pestell, MD, PhD, FRACP Director, Kimmel Cancer Center at Jefferson1
Preparing for Your First Visit

Preparing for your appointment is the best way to assure that you have a visit that is as successful and
productive as possible. You will need to set aside a certain amount of time for the visit and allow for a
number of steps.
The following list may help make your appointment go smoothly.
• Arrive 30 minutes early so that you have time to complete any needed paperwork.
• Review your medical and family history and/or bring the completed health questionnaire
which may have been sent to you. This information will help us care for you.
• Bring a list of your current medications and allergies or drug reactions.
• Please bring your insurance information, including your insurance card with ID number and
group number and prescription plan information.
• Please bring referrals from your primary care provider if your insurance requires.
• You will need to be prepared to pay any in-office co-payments necessary.
• Please bring any relevant radiologic images (x-rays, ultrasounds, PET, CT,
MRI, bone scans and others – in either film or CD-ROM format) and
pathology slides and their written reports.
• We suggest you bring a pen and paper to take notes and think about questions you
would like to ask.
• If you have one, bring a copy of your advance directive (living will).
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Questions to Ask When Visiting

Before and during your visit, think about what questions you need to have answered by your healthcare
provider. This may include information about staging of your condition, side effects of treatment, next
steps in care, medications, follow-up, limitations after treatment, or other matters.
The following are questions you may want to ask when visiting your doctor or other healthcare
providers. Not every question will apply to you. They are meant to be ‘things to consider’ and some can
be asked either at your initial visit or further along in treatment.
• Is my cancer something that you see often? • How long will treatment last?
• What type of cancer do I have? • Are there tests that determine how my
cancer responds to treatment?
• Is my cancer local or has it spread? What is
the stage of my cancer? • Will you change my treatment if it appears
not to be working?
• What treatments are considered the best
or gold standard for my cancer? Are there • How often will I see you during and
other treatment options? after treatment?
• Does this institution have access to all • What signs or symptoms
these treatments? If not, where can I should I bring to your
receive these treatments, locally and attention?
institutions at further distances?
• Who do I call if I have a
• What are the pros and cons and side effects question or concern? How
of these treatment options? do I reach them?
• Are there any clinical trials that I may be • What is the goal of my
eligible to participate in? treatment? Do you expect
• If treatment is done here, who will a cure from these
treatments?
be clinically in charge of my care, a
quarterback of sorts? And who will be the • What percentages
other treatment team members? of patients with
• Will receiving this treatment prevent me my type of
cancer live 5
from getting another or different type of
years or more?
treatment in the future?
• Will this treatment affect my ability to have • What is my
chance of a
children in the future?
recurrence of
• Are there any more tests which need to be
this cancer
done before making final decisions on the
and chance of
treatment plan?
another cancer?
• What are the survival rates with
these treatments?
• Are these treatments covered by my
health insurance?
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Insurance Information

Your insurance information will be needed for your healthcare provider visits. You should bring your
insurance card and prescription card with you to every visit.
It may be helpful for you to keep a copy of your insurance card (front and back) in the pocket of this
patient planner and keep a copy of the information, handwritten, in the area below.
From Your Insurance Card
Primary Carrier:
ID #:
Group/Plan #:
Subscriber’s Name:
Relationship to Patient:

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Physician Information

Keeping your primary care physician information with you will be helpful, especially if you need to get
a referral for the specialists you are seeing at the Jefferson Kimmel Cancer Center.
Primary Care Physician (PCP):
Address:
Telephone:
Fax:

Referral Information

The information below will be needed if a referral from your primary care physician is required from
the specialist you are being referred to. Ask the specialist’s staff or appointment scheduling staff to
provide you with this information.
Physician: Specialty:
Office Address:
Date of Appointment: Reason for Referral:
Referred to: Provider Number:

Other Physicians Involved in Your Care

Please list any physicians involved in your medical care including specialists and other cancer doctors.
Name City State
Please list any doctors you would like to have reports sent to:
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Multidisciplinary Treatment Team
Title Name Phone Number
Primary Care Doctor
Medical Oncologist
Radiation Oncologist
Surgeon
Radiation Therapist
Nurse Practitioner
Physician Assistant
Nurse
Nurse
Nurse
Social Worker
Home Care Agency
Other:
Other:
Other:
Other:
Other:
Other:
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Medications

Please list all medications you are taking including the dose if possible. Be sure to include
over the counter medications that you take on a regular basis such as aspirin, Motrin,
Advil, Nuprin, etc. Include vitamins, herbs and any other supplements as well.
Pharmacy Pharmacy Phone Pharmacy Fax
Medication/Dose: Start Date: Prescribing Physician: Reason you are taking: Stop Date:
Medication/Dose: Start Date: Prescribing Physician: Reason you are taking: Stop Date:
Medication/Dose: Start Date: Prescribing Physician: Reason you are taking: Stop Date:
Medication/Dose: Start Date: Prescribing Physician: Reason you are taking: Stop Date:
Medication/Dose: Start Date: Prescribing Physician: Reason you are taking: Stop Date:
Medication/Dose: Start Date: Prescribing Physician: Reason you are taking: Stop Date:
Medication/Dose: Start Date: Prescribing Physician: Reason you are taking: Stop Date:
Medication/Dose: Start Date: Prescribing Physician: Reason you are taking: Stop Date:
Medication/Dose: Start Date: Prescribing Physician: Reason you are taking: Stop Date:
Medication/Dose: Start Date: Prescribing Physician: Reason you are taking: Stop Date:
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Allergies
If you are allergic to any medication, please list them and how you react to the medication:
Medicine Reaction
Medicine Reaction
Medicine Reaction
Medicine Reaction
Medicine Reaction
Medicine Reaction
Medicine Reaction
Medicine Reaction
Please list any other allergies such as dyes, soaps, food, IV CONTRAST, etc. and your reaction to them:
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Finding Your Way
Arch Street
Filbert Street
SEPTA Market East Station
Market Street
Ludlow Street
VP 25 S. 9th
1021tuntsehC 1015Chestnut BookstoreComm. Svcs.Photo ID VictoryBuilding Che9s2t5nut Chest8n3u3t East
Chestnut Street
VP
Ben Franklin
Gibbon House
834 Chestnut
Bodine Center
VP Sansom Street
reredreoFnoilivaP ThCoomllpesgoen MaCinurtis Nevil 909EdWalnutison Sheridan
Walnut Street
1100Walnut nitraMHamilton Scott ztiwolrO Barringer BluemleLife Sciences Neuroscience TWoawlneurst Wills Eye Institute
Building
Locust Street
Street Direction
Alumni Hall
12th Street 11th Street Irving Street 10th Street 9th Street EVPmaarleektri gnPegan rGckayinr Eagngtersa/nLcoets
(Entrances Noted)
1 Gibbon Building 111 South 11th Street 10 Hospital for Neuroscience 900 Walnut Street
2 Clinical Laboratory 125 South 10th Street 11 908 Walnut Street
3 1015 Chestnut Street 12 Clinical Offi ce Building 909 Walnut Street
4 925 Chestnut Street 13 Main Building 132 South 10th Street
5 25 South 9th Street 14 Thompson Building – Enter through
6 833 Chestnut Street Foerderer Pavillion 125 South 11th Street
7 Ben Franklin House 834 Chestnut Street 15 Kimmel Cancer Center - Bodine Building
8 Walnut Towers 850 Walnut Street Corner 11th & Sansom Streets
9 834-840 Walnut Street 16 Medical Offi ce Building 1100 Walnut Street
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