1 : Patient Details. 2 : Medical Aid Details. 3 : Practitioner Detail (Practice) 4 : Patient History

Transcription

1 1 : Patient Details Surname: Firstname: Initials: ID Number: First Diagnosed: Gender: Telephone: CellPhone: Dependant Code: Birth: Postal Address Fax: 2 : Medical Aid Details Principal Member: Membership Number: Medical Aid: Benefit Option: 3 : Practitioner Detail (Practice) Contact Person: Address: Practice Number: Telephone Number: Group Practice: HPCSA Number: Fax Number: Emergency Urgent 4 : Patient History Diagnosis and Criteria for PMB Condition ICD Code: Histology: Primary Site: First Diagnosis PMB Code: Condition: Metastatic Spread To Adjacent Organ Evidence of Distant, Metastatic Spread Irreverible/ Irreparable damage to organ of origin or other vital organ Well demonstrated 5 year survival rate of greater than 10%

2 ICD Code: Primary Site: Second Diagnosis and Criteria for PMB Condition Histology: Second Diagnosis PMB Code: Condition: Metastatic Spread To Adjacent Organ Irreverible/ Irreparable damage to organ of origin or other vital organ Evidence of Distant, Metastatic Spread Demonstrated 5 year survival rate for this cance is greater than 5% 5 : Other Clinical Information Grade: ECOG Scale: AJCC: Disease Stage T: N: M: Stage Other: Metastases: Bone Brain Liver Lung Other: Receptors: Co-Morbid: Treatment History Date Descr Drugs Outcome Comments

3 6 : Treatment Intent and Review Plan Effective Treatment Intent: SAOC Level: Clinical Trial : Hormone Manipulation Radiotheapy Chemotherapy: Other: Hospital Practice No: Hospital Hospital Motivation: Additional Comments: Treatment Review: Practitioner Signature:

4 7 : Radiotherapy Treatment - (RAD) Professional Practice No.: Professional Fees: Technical Practice No.: Technical Fees: Start Date.: Area of Interest: Supporting Items : Duration in Weeks: Dose: Radiotherapy : Prostate Volume: Gleason Grade: PSA: IPSS: Prostate Stage: Hospital : Radiotherapy Comments: Radiotherapy Planning Code Product Name Commencement Week(s) UnitPrice Code Professional Technical Radiation Code Radiotherapy Planning Code Sub : Product Name Commencement Week(s) UnitPrice Code Professional Technical Radiation Code Sub :

5 Product Name Commencement Week(s) UnitPrice Code Professional Technical Isotope Brachy Code Isotope Sub : Product Name Commencement Week(s) UnitPrice Code Professional Technical Supporting Items and Materials Brachy Code Sub : Product Name Commencement Week(s) UnitPrice Code Supporting Items and Materials Sub :

6 8 : Chemotherapy Treatment - (CHEM) Professional Practice No.: Chemo Prov Practice No.: Facility Practice No.: Starting Date.: Height: Weight: Body Surface: Chemotherapy Comments: StartDate s Chemotherapy : Part 1 Cost Cost Port Insertion Hospital: Chemotherapy Service Fees Chemotherapy Service Fees Sub :

7 Chemotherapy Drugs Chemotherapy Drugs Sub : Supporting Drugs, Materials and Fluids Supporting Drugs, Materials and Fluids Sub :

8 StartDate s Chemotherapy : Part 2 Cost Cost Port Insertion Chemotherapy Service Fees Hospital: Chemotherapy Service Fees Sub : Chemotherapy Drugs Chemotherapy Drugs Sub : Supporting Drugs, Materials and Fluids Supporting Drugs, Materials and Fluids Sub :