Oncology Follow Up Maintenance

---
name: oncology-follow-up-maintenance
description: |
  Plan follow-up and maintenance so gains for patients diagnosed with cancer and their families are checked and sustained.
  TRIGGERS - Use when a oncologist needs a follow-up & maintenance schedule for patients diagnosed with cancer and their families in a cancer centre and oncology day unit.
category: Oncology
license: MIT
version: 1.0
---
# Follow-Up & Maintenance Schedule — Oncology

Plan follow-up and maintenance so gains for patients diagnosed with cancer and their families are checked and sustained. The deliverable is a follow-up schedule with intervals, checks and escalation triggers.
This skill is written for a oncologist working with patients diagnosed with cancer and their families in a cancer centre and oncology day unit.

## When to use
- You are a oncologist preparing, delivering or reviewing this part of your work in a cancer centre and oncology day unit.
- You need a defensible, repeatable approach that produces a follow-up schedule with intervals, checks and escalation triggers.
- A colleague, auditor or client asks how this was done and what evidence supports it.

## Key Concepts
| Term | Meaning |
|------|---------|
| Staging | classifying how far a cancer has spread |
| Adjuvant therapy | treatment given after primary therapy to reduce recurrence risk |
| Neutropenia | abnormally low neutrophil count raising infection risk |

## Workflow
1. **Step 1** - Set follow-up intervals from the plan and from how time from diagnosis to first treatment is expected to move over time
2. **Step 2** - Define what is checked at each contact, using infusion pumps where measurement is needed, and record it in staging reports
3. **Step 3** - Give patients diagnosed with cancer and their families clear guidance for the interval: what to do, what to watch for, when to make contact sooner
4. **Step 4** - Act early on warning signs — deterioration linked to delayed diagnosis shortens the interval, never lengthens it
5. **Step 5** - Close the follow-up cycle formally when goals are met, with a summary and re-entry route if needs return

## Profession-Specific Components
| Component | Details for Oncology |
|-----------|-------------------------------|
| Core documentation | staging reports; treatment plans; chemotherapy prescriptions; radiotherapy summaries |
| Core tools & equipment | infusion pumps; radiotherapy planning systems; PET-CT imaging; port access devices |
| People involved | patients diagnosed with cancer and their families; the oncologist; colleagues and other services in a cancer centre and oncology day unit |
| Primary record | staging reports — keep it current, dated and attributable |

## Output Format
**Context:** [Situation in a cancer centre and oncology day unit] | **Objective:** [What this must achieve] | **Audience:** [patients diagnosed with cancer and their families and other stakeholders]

The finished output is a follow-up schedule with intervals, checks and escalation triggers, structured as:
1. Summary of position and evidence
2. Detail, following the workflow above
3. Decisions, actions, owners and dates
4. Review point and escalation route

### Action Plan
1. **Immediate:** Confirm scope, consent and the evidence available in staging reports.
2. **Short-term:** Complete the workflow steps and record outcomes against time from diagnosis to first treatment.
3. **Medium-term:** Review results, close actions, and update local procedures in a cancer centre and oncology day unit.

## Success Metrics
| Metric | Target | Method |
|--------|--------|--------|
| time from diagnosis to first treatment | Agree a local target and track the trend | Measured from staging reports and reviewed on a set cycle |
| treatment completion rate | Agree a local target and track the trend | Measured from staging reports and reviewed on a set cycle |
| grade 3-4 toxicity rate | Agree a local target and track the trend | Measured from staging reports and reviewed on a set cycle |
| one-year survival follow-up rate | Agree a local target and track the trend | Measured from staging reports and reviewed on a set cycle |

## Guardrails & Quality Checks
- Never let this happen: delayed diagnosis.
- Never let this happen: chemotherapy prescribing errors.
- Never let this happen: unmanaged treatment side-effects.
- Work only within the competence and authority of a oncologist; escalate or refer anything beyond it.
- Record facts and observations, not speculation, and keep records confidential to a cancer centre and oncology day unit's rules.
- Verify names, dates, figures and measurements twice before anything is issued or signed off.
- Use only real, verified information from the case in hand — never invent results, credentials or evidence.

## Example (illustrative)
A oncologist in a cancer centre and oncology day unit applies this workflow for patients diagnosed with cancer and their families: they open
staging reports, work through the five steps using infusion pumps, and close by recording
the outcome against time from diagnosis to first treatment and agreeing the next review date. (Illustrative example only —
replace with the real details of the case in hand.)