Screening Tools

Sample Letters (Patients and Referring Providers)

Shared by Lahey Hospital & Medical Center:

• Screening results letter to patient [screening, return for follow-up LDCT in 1-2 months]
• Screening results letter to patient [screening, small lymph node, follow-up LDCT recommendation]
• Screening results letter to patient [screening, small lymph node, contact healthcare provider to discuss]
• Screening results letter to patient [screening, 1 or more small lung nodules, likely benign LDCT recommended follow-up date]
• Follow-up LDCT screening exam 30-day reminder letter to patient
• Follow-up LDCT screening exam letter to referring physician
• Follow-up LDCT screening exam 90-day reminder letter to patient
• Follow-up LDCT screening exam 90-day reminder letter to referring physician

The following samples were shared by Middlesex Hospital—Total Lung Care Center:

• Screening results follow-up letter to patient
• Screening results follow-up letter to referring physician

Questionnaires

Shared by Middlesex Hospital—Total Lung Care Center:

• CT Lung Patient Risk Questionnaire

Shared by KentuckyOne Health:

• LDCT Questionnaire and Physician Order Form

Process Resources

Shared by KentuckyOne Health:

• Flowchart: LDCT Lung Cancer Screening Program Cancer Prevention Services
• Lung Cancer Screening Pack-Year Calculator
• Lung Cancer Screening Risk—Benefit Information for Patients
• Lung Cancer Screening LDCT Program Step-by-Step for PCP offices
• LDCT Lung Cancer Screening Physician Referral Criteria Guidelines
• LDCT Internal Scheduling Procedure

Shared by WellStar Health System:

• Lung Cancer Screening Patient Information Guide
• Lung Cancer Screening History Assessment Form
• Lung Screening Research Registry Information Sheet for Patients

Shared by Northwest Community Healthcare:

• LDCT Lung Cancer Screening Program Consent Form
• LDCT Lung Cancer Screening Chart Documentation

Marketing Materials

Shared by Middlesex Hospital—Total Lung Care Center:

• Lung Cancer Screening: Take the First Step to Find Out if You are at High Risk

Shared by St.JosephHealth, St. Joseph Hospital:

• Flyer for physician education dinner on Lung Cancer: Prevention, Screening and Treatment