Mental Health Study Chart Audit Form (Page 2 of 4) in pdf

Mental Health Study Chart Audit Form Page 2

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MENTAL HEALTH STUDY CHART AUDIT FORM

Patient’s Current Stage of Advanced Disease (check

only one):

D1: Pelvic lymph node metastasis or ureteral obstruction causing hydronephrosis or both ____

D2: Bone, soft tissue, organ, or distant lymph node metatstasis _____

Patient’s Current Disease Status (check

only one):

1) Hormone Sensitive: stable PSA < 1.0 on hormone suppression therapy ____

(may have new diagnosis of advanced prostate cancer or recurrent disease following previous

treatment for early stage disease)

2) Hormone Refractory: ____

Meets these criteria:

a) 3 progressive rises in PSA following a response to androgen suppression therapy

Date 1: ________

PSA = ______ ug/L

Date 2: ________

PSA = ______ ug/L

Date 3: ________

PSA = ______ ug/L

b) Asymptomatic, stable symptoms, or symptoms responsive to treatment

c) Has not required mitoxontrone chemotherapy

3) Hormone Refractory Receiving Palliative Care: ______

Meets all these criteria:

Hormone Refractory as above with continued rise in PSA

Date 1: ________

PSA = ______ ug/L

Date 2: ________

PSA = ______ ug/L

Date 3: ________

PSA = ______ ug/L

b) New symptoms and/or progressive symptoms such as pain, fatigue, weight loss, or nausea

c) Completed course of mitoxantrone chemo, or was not eligible to receive mitoxontrone

because of cardiac status

d) Requiring aggressive pain and symptom management such as: escalating analgesia, steroids,

palliative radiation, strontium

Mental Health Study Chart Audit Form Page 2