Blood and Marrow Transplant Patient Information Sheet

Transcription

1 Blood and Marrow Transplant Patient Information Sheet Patient Name MR# DOB Diagnosis Wt. (kg) Ht. (cm) M2 Ethnicity: Sex: UPN # 0.00 BMT Attending: Name Allergies: BMT Coordinator: Name Donor Information: HLA: / 6 ( / 8 ) Type of Transplant MR/ID# Wt. Ablative Non-Ablative Reduced Intensity DOB/Age Sex GVHD Prophylaxis: Stem Cell Processing: None CSP/Pred ATG MTX CSP CSP/MTX T-cell depletion Stem Cell Source: Auto Syngeneic Testicular Irradiation: Yes No Related Un-Related Cranial Irradiation: Yes No Intrathecal Medication: Yes No Relationship: Treatment and Studies: Date Signed Stem Cell Product Type: Cord Blood PBSC Marrow Cell Dose: Back-up: Date of Harvest: Diagnosis Information: BMT Treatment Summary: Stage: Grade: Day Date Treatment Dose Primary Site: Metastatic Sites: Date of Diagnosis: Relapse Dates: Current Disease Status: Prior Research Studies: Prior Radiation: Prior Chemo: Prior BMT: Therapy: Total anthracycline/m2: Medical History: Current L/K Score: Significant coexisting diseases: Transfusion and Premed Information: Pre-Med Blood Products Yes No Benadryl mg Tylenol mg BMT Attending Signature: BMT Coordinator Signature: Date: Date: Page 1

2 Blood and Marrow Transplant Patient Information Sheet Evaluation Results: Patient MR# Name Referral Information: LAB ABO/Rh CMV HSV PATIENT DATE DONOR DATE Referring Institution Referring Physician RMD Address HepB surface Ag HepB Core AB HepA IgM/IgG HIV NAT or HIV p24 ag HTLV (1 & 2) HepC AB (virus) RMD Phone Number RMD Fax Number RMD Private Physician PMD Address EBV VZV Syphilis Toxo IgG Orsa VRE Creatinine/BUN T. bili SGOT/SGPT PMD Phone PMD Fax PMD Rad/Onc Nutrition Psych/SocialWorker Dental Surgeon ENT Physician B-HCG Anti A/B titer Patient/Family Information: Evaluation Results Date Parents Cr. Clearance/GFR /1.73 sq.m2 Parents' Address MUGA or echo EKG Parents' Phone 's / O2 sat Work Phone: BM bx & asp Parent's Lumbar Puncture Marital Status Scans: Occupation Patient Lab Values Lab Value Date Venous Access Double Lumen CVC Coments: Mediport Single lumen CVC Double Lumen Apheresis CVC I have personally reviewed all evaluations and at this time the Patient and donor are acceptable to proceed with the proposed transplant procedure. BMT Attending Signature: Date: BMT Coordinator Signature: Date:

3 Ins. Company's Name Address To whom it may concern, We are sending you this letter to request financial approval for our patient, PATIENT Name. Please find enclosed the clinical information packet, which includes organ function tests and viral lab results along with a summary letter from the patient's attending Physician. This information is provided for your review on our patient, PATIENT Name. At this time we have completed all of the Pre-Bone Marrow Transplant (BMT) evaluation. After reviewing the current status and results from the evaluation and consultation with the family, we feel PATIENT Name is ready to proceed to Bone Marrow Transplant. (Please include the type of BMT, i.e. MUD, MSD, Cord) It is our assessment that the greatest probability of long-term disease-free survival is with a Bone Marrow Transplant. Based on our findings, we are requesting financial approval to treat this patient with the therapy outlined in this packet of information. Following approval we would proceed to a Bone Marrow Transplant using Treatment Plan/Protocol. We thank you for considering this request and we look forward to your reply. If you have any questions, or need additional documentation, please do not hesitate to contact Carol Page RN, Transplant Finance Supervisor or Mark Mueller RN Blood and Marrow Transplant Mark Mueller RN Blood and Marrow Transplant Coordinator Phone: Carol Page RN Transplant Finance Supervisor Phone:

4 Blood and Marrow Transplant Multidisciplinary Meeting Date: Name Print Signature

5 Patient Name MR# BMT MD: Name BMT Coordinator: Home Phone: Cell Phone: Home Care: Pharmacy: BMT Summary and Plan: Name Follow up: Weekly Monthly Every 3 months BMT Long Term follow-up Date 6 Mo BMT F/U 9 Mo BMT F/U Disease evaluation (Scans, labs etc) 1 Yr BMT F/U Immunizations Disease evaluation (Scans, labs etc) 18 Months BMT F/U 2 Yr BMT F/U Immunizations Disease evaluation (Scans, labs etc) 2 yr 6 mo BMT F/U 3 Yr BMT F/U Immunizations 4 Yr BMT F/U Immunizations 5 Yr BMT F/U Immunizations 6 Yr BMT F/U Immunizations 7 Yr BMT F/U Immunizations BMT F/U labs should include CBC w/diff, Renal and Liver panel, Ca. Mg and Phos

6 Name of Patient: Medical Record: Date: Visit: up to Day month year ACUTE GVHD Has patient developed acute GVHD for the first time or a severe flare since last visits or post Day 100? NO YES Date of Onset: Diagnosis based on : Histologic Evidence Site Date of Biopsy Clinical Evidence Overall severity of acute GVHD since last contact: Maximum overall grade: I II III IV Stage 0 Stage 1 Stage 2 Stage 3 Stage 4 Degree of Certainty maculopapular generalized general erythrodema rash<25% rash 25-50% erythrodema with bullous formation SKIN No Rash maculopapular GI LIVER No Diarrhea billrubin (<2 mg/dl) Diarrhea ( ml/m 2 Diarrhea ( ml/m 2 ) billrubin ( mg/dl) billrubin ( mg/dl) Diarrhea (>833 ml/m 2 ) billrubin ( mg/dl) Severe abdominal pain, with or without ileus billrubin (>15 mg/dl) Does patient still have symptoms of AGHVD: Yes No. Specific therapy used to treat AGVHD: Please indicate whether meds were started or continued at prophylactic level Is patient still taking immunosuppressive agents to treat or prevent GVHD? Yes No Date stopped Mo/Year Please rate the overall Lansky/Karnofsky Scale of the patient since last contact: Lansky Scale (10-100) for <16 years old Karnofsky Scale (10-100) for > 16 years old Select the phrase in the Lansky-Play-Performance Scale Select the phrase in the Karnofsky Scale which best describes which best describes the activity status of the patient. the activity status of the patient. Normal range 100 Fully active 90 Minor restriction in physically strenuous play 80 Restricted in strenuous play, tires more easily, otherwise active Mild to moderate restrictions 70 Both greater restrictions of, and less time spent in active play 60 Ambulatory up to 50% of time, limited active play with assistance/supervision 50 Considerable assistance for any active play; fully able to engage in quite play Moderate to severe restriction 40 Able to initiate quite activities 30 Needs considerable assistance for quit activities 20 Limited to very passive activity initiated by others (eg: TV) 10 Completely disabled, not even passive play Able to carry on normal activity; no special care is needed 100 Normal; no complaints; no evidence of disease 90 Able to carry on normal activity 80 Normal activity with effort Unable to work; able to live at home, care for most personal needs; a varying amount of assistance is needed 70 Cares for self; unable to carry on normal activity or to do active work 60 Requires occasional assistance but is able to care for most needs 50 Requires considerable assistance and frequent medical care Unable to care for self; requires equivalent of institutional or hospital care; disease may be progressing rapidly. 40 Disabled; requires special care and assistance 30 Severely disabled; hospitalization indicated, although death not imminent 20 Very sick; hospitalization necessary 10 Moribund; fatal process progressing rapid SIGNATURE

7 Name of Patient: Medical Record: Date: Visit: months year CHRONIC GVHD Has patient developed clinical chronic GVHD since last visits? NO YES Date of Onset: Did this progress from Acute GVHD? Yes Diagnosis based on : Histologic Evidence Site Date of Biopsy Clinical Evidence Overall severity of chronic GVHD since last contact: mild signs and symptoms of chronic GVHD do not interfere substantially with function and do not progress once appropriately treated with local therapy or standard systemic therapy (steroids and/or cyclosporine FK 506) moderate-signs and symptoms of chronic GVHD interfere somewhat with function despite appropriate therapy or are progressive through first line systemic therapy defined as steroids and/or cyclosporine or FK 506 severe signs and symptoms of chronic GVHD limit function substantially despite appropriate therapy or are progressive through second line therapy Maximum grade of chronic GVHD limited extensive Does patient still have symptoms of CGHVD: Yes No. Please check if there was organ involvement with CGVHD from list below: Skin involvement (BSA % ) Eyes Contractures Lung involvement Oral involvement Arthritis Weight Loss Thrombocytopenia Esophageal Involvement Chronic diarrhea Malabsorption Abnormal pain/cramps Chronic nausea/vomiting Myositis Myasthenia, specify Specific therapy used to treat CGVHD: Please indicate whether meds were started or continued at prophylactic level Is patient still taking immunosuppressive agents to treat or prevent GVHD? Yes No Date stopped Mo/Year Please rate the overall Lansky/Karnofsky Scale of the patient since last contact: Lansky Scale (10-100) for <16 years old Karnofsky Scale (10-100) for > 16 years old Select the phrase in the Lansky-Play-Performance Scale Select the phrase in the Karnofsky Scale which best describes which best describes the activity status of the patient. the activity status of the patient. Normal range 100 Fully active 90 Minor restriction in physically strenuous play 80 Restricted in strenuous play, tires more easily, otherwise active Mild to moderate restrictions 70 Both greater restrictions of, and less time spent in active play 60 Ambulatory up to 50% of time, limited active play with assistance/supervision 50 Considerable assistance for any active play; fully able to engage in quite play Moderate to severe restriction 40 Able to initiate quite activities 30 Needs considerable assistance for quit activities 20 Limited to very passive activity initiated by others (eg: TV) 10 Completely disabled, not even passive play Able to carry on normal activity; no special care is needed 100 Normal; no complaints; no evidence of disease 90 Able to carry on normal activity 80 Normal activity with effort Unable to work; able to live at home, care for most personal needs; a varying amount of assistance is needed 70 Cares for self; unable to carry on normal activity or to do active work 60 Requires occasional assistance but is able to care for most needs 50 Requires considerable assistance and frequent medical care Unable to care for self; requires equivalent of institutional or hospital care; disease may be progressing rapidly. 40 Disabled; requires special care and assistance 30 Severely disabled; hospitalization indicated, although death not imminent 20 Very sick; hospitalization necessary 10 Moribund; fatal process progressing rapid SIGNATURE

8 Lansky Scale (10-100) for <16 years old Select the phrase in the Lansky-Play-Performance Scale which best describes the activity status of the patient. Normal range 100 Fully active 90 Minor restriction in physically strenuous play 80 Restricted in strenuous play, tires more easily, otherwise active Mild to moderate restrictions 70 Both greater restrictions of, and less time spent in active play 60 Ambulatory up to 50% of time, limited active play with assistance/supervision 50 Considerable assistance for any active play; fully able to engage in quite play Moderate to severe restriction 40 Able to initiate quite activities 30 Needs considerable assistance for quit activities 20 Limited to very passive activity initiated by others (eg: TV) 10 Completely disabled, not even passive play Karnofsky Scale (10-100) for > 16 years old Select the phrase in the Karnofsky Scale which best describes the activity status of the patient. Able to carry on normal activity; no special care is needed 100 Normal; no complaints; no evidence of disease 90 Able to carry on normal activity 80 Normal activity with effort Unable to work; able to live at home, care for most personal needs; a varying amount of assistance is needed 70 Cares for self; unable to carry on normal activity or to do active work 60 Requires occasional assistance but is able to care for most needs 50 Requires considerable assistance and frequent medical care Unable to care for self; requires equivalent of institutional or hospital care; disease may be progressing rapidly. 40 Disabled; requires special care and assistance 30 Severely disabled; hospitalization indicated, although death not imminent 20 Very sick; hospitalization necessary 10 Moribund; fatal process progressing rapid