Chemotherapy Administration/Infusion Note (Pediatric Oncology)

Date: [Date]

Location: [clinic / infusion center / inpatient unit]

Patient Name: [Patient name]

DOB: [DOB]

MRN: [MRN]

Ordering Oncologist: [Name, credentials]

Administering Clinician: [Name, role/credentials]

Treatment Context

Diagnosis/Indication: [Diagnosis/indication]

Regimen/Protocol: [Regimen/protocol name, protocol number if applicable] [on-trial / off-trial] (If regimen name unavailable, state explicitly and document source of orders used.)

Cycle/Day: [Cycle number] / [Day number]

Planned vs. Administered: [One-line summary of planned agents and what was actually administered]

Pre-Administration Safety

• Allergies/Hypersensitivity History Reviewed: [Relevant agents and reactions, or "No known drug allergies"]
• Anthropometrics: Height [height] cm; Weight [weight] kg; BSA [BSA] m² (Include BSA if BSA-based regimen.)
• Consent Verification: [On file / Verified today / Not documented] (Include assent/parental consent status if applicable.)
• Two-Person Independent Verification: Completed.
  • Verifier 1: [Name, role]
  • Verifier 2: [Name, role]
  • Verified in patient/caregiver presence: patient identifiers, drug name, dose, route, rate/duration, cycle/day, expiration date, product integrity, line/tubing appropriateness.
  • Barcode Scan: [Completed / Not available / Overridden with reason]
• Vascular Access: [port / PICC / CVC / PIV]; Site [anatomic site]; [left / right / midline]; Lumen [lumen used]; Blood return [present / absent]; Baseline site assessment [clean/dry/intact, presence or absence of pain, swelling, erythema].
• Labs/Parameters: [Reviewed and within parameters / Pending / Out of range] (If proceeding with pending or out-of-range results, document approving provider name and time of authorization.)

Administration Record

(Include all administered or attempted items: antineoplastics, premedications, hydration, and rescue/reaction medications. Do not infer or back-calculate times. Document rate changes or interruptions as time-stamped entries in Comments.)

Seq	Medication (generic)	Dose (with calculation basis)	Route	Access/Lumen	Rate	Start Time	Stop Time	Status	Comments
[#]	[Medication generic name]	[Dose expression, e.g., X mg/m² = Y mg]	[IV / PO / SQ / other]	[Access type and lumen]	[Rate or duration]	[HH:MM]	[HH:MM / Not recorded]	[Given / Partially given / Held / Stopped early]	[Reason if not fully given; rate changes with timestamps; interruptions]

(Add rows for each medication administered or attempted.)

Monitoring and Tolerance

• Baseline (pre-chemotherapy): Vital signs [values]; Pain [score and scale]; Nausea/emesis [none / mild / moderate / severe]; General appearance [brief description].
• Mid-infusion: [Vital signs with times] (Include only if required by agent/protocol or if symptoms occurred; if monitoring was limited, document reason.)
• End-of-infusion: Vital signs [values]; Pain [score]; Nausea/emesis [status]; General appearance [brief description].

Patient tolerance: [Objective tolerance statement] (Do not document "no reaction" unless monitoring actually occurred; if monitoring was limited, state extent and reason.)

Adverse Events

(Include this section only if an event occurred. If no event and institutionally required, use single line: "No infusion reaction or extravasation observed.")

Hypersensitivity/Infusion Reaction

(Include only if reaction occurred.)

• Suspected agent: [Medication]
• Onset: [Time] ([minutes] from infusion start)
• Signs/symptoms: [Objective description; include patient quote for subjective symptoms]
• Vital signs during event: [Values with times]
• Severity grade: [Grade per local scale, if used]
• Immediate actions: [Stopped infusion / maintained IV / oxygen / fluids / other]
• Medications administered: [Drug, dose, route, time for each]
• Provider notification: [Who notified, when]
• Orders received: [New orders/interventions]
• Disposition: [Resumed at reduced rate / Discontinued / Transferred to higher level of care / Observation period]
• Outcome: [Resolved / Improving / Ongoing]
• Follow-up plan: [Plan]

(If epinephrine or emergency response occurred, document time, response, and who led management.)

Extravasation/Infiltration

(Include only if extravasation/infiltration occurred.)

• Suspected agent: [Agent]; Vesicant classification: [vesicant / irritant / non-vesicant]
• Access type/site: [Port / PICC / CVC / PIV]; [Site]
• Recognition time: [HH:MM]; Estimated volume infiltrated: [mL / Unable to estimate]
• Site signs/symptoms: [Pain, burning, swelling, erythema, blistering]
• Immediate actions: [Infusion stopped; aspiration attempted; line discontinued at time]
• Antidote/compress therapy: [Agent, dose, schedule; warm/cold compress details]
• Consults: [Plastic surgery / wound care / pharmacy / other, or none]
• Education and return precautions: [What was provided to patient/caregiver]
• Follow-up plan: [Plan and timeframe]

Deviations from Plan

(Include this section only if a deviation occurred.)

• Change: [Dose reduction / Hold / Early stop / Substitution / Rate change / Other]
• Reason: [Labs / Toxicity / Prior reaction / Drug availability / Caregiver request / Other]
• Authorizing clinician: [Name, role] at [HH:MM]
• Impact on regimen: [Implications, if applicable]
• Family informed: [Yes / No]; [Who was informed]

End-of-Infusion Status

• Completion status: [All intended infusions complete / Stopped early] (If stopped early, reference Deviations section.)
• Patient condition: [Stable / Symptomatic]; Pain [score/description]; Nausea/emesis [status]
• Line status: Blood return [verified / not required]; [Flushed and locked]; Dressing [clean/dry/intact]; [De-accessed / Remains accessed with rationale]
• Discharge instructions provided: [Return precautions, when to call clinic, fever threshold]
• Next steps: [Next appointment, labs scheduled, other instructions]