Chemotherapy Day-of-Treatment Assessment Note (Pediatric Oncology)

Date/Time of Assessment: [Date and time]

Location: [infusion center / inpatient / procedural suite]

Patient Name: [Full name]

DOB: [MM/DD/YYYY]

MRN: [Medical record number]

Primary Diagnosis: [Primary diagnosis] — [newly diagnosed / remission / relapse / maintenance]

Protocol/Regimen: [Study name and number / non-protocol therapy]

Cycle/Day: [Cycle # / Day #]

Planned Therapy Today: [Agents and routes]

Allergies & Prior Reactions: [Allergen(s), reaction type(s), and established premedication/mitigation plan if applicable; document NKDA if none]

Clinician: [Name, credentials, role] (Include supervising clinician if applicable.)

Interval History & Toxicity Screen

[Narrative since last chemotherapy or oncology visit covering intercurrent events, medication adherence issues, and caregiver concerns. Follow with focused toxicity screening prioritizing systems relevant to planned agents—expand positive findings with severity/grade when on protocol; note pertinent negatives briefly. Use direct patient/caregiver quotes for safety-relevant descriptors, then translate into clinical terms. If a symptom cannot be assessed, state reason. Do not fabricate normal findings.]

Objective

Performance Status: [Lansky or Karnofsky score] — [brief functional descriptor] (If unable to score due to age/development, provide age-appropriate functional description.)

Vitals: [Temp, HR, RR, BP, SpO2, pain score as measured]

Weight/Dosing Parameter: [Weight in kg; height if measured; BSA or dosing basis] (Note significant change from baseline.)

Focused Exam: [Pertinent findings—general appearance, oral mucosa, cardiopulmonary, abdomen, skin, line/port site, neurologic screen as relevant to planned agents]

Labs: [Date/time drawn and resulted; ANC, Hgb, platelets, creatinine, bilirubin, AST/ALT, electrolytes, and regimen-specific tests as applicable] (If pending: "Pending—clearance deferred until reviewed." If outside labs, note source.)

Clearance Determination

Disposition: [Proceed with therapy as planned / Proceed with modified doses or schedule (specify) / Hold therapy today (specify reason) / Defer decision pending labs or consultation (specify timeframe)]

[Confirm: vitals and performance status reviewed; allergies and prior reactions reviewed; toxicities assessed; key labs reviewed and meet protocol parameters—or specify which do not and action taken. If pregnancy risk assessment applies, document status. State clearance explicitly with supporting rationale.]

Dose Modifications

(Required on every note.)

[No dose holds or modifications today.]

(If modifications exist, document for each agent: original vs. modified dose; type of change—hold, delay, reduce, or omit; rationale linked to toxicity grade, lab value, or clinical finding; whether protocol-directed or provider discretion; notifications made—attending, pharmacy, research coordinator if on trial; and re-evaluation plan.)

Plan

• Therapy today: [Chemotherapy plan with supportive measures—premedications, hydration, antiemetics, prophylaxis]
• Toxicity/symptom management: [Interventions for current toxicities or symptoms]
• Line/Port access: [Access plan and any troubleshooting]
• Follow-up: [Next infusion date; next labs with timing; return precautions and ED criteria]
• Education: [Plan and warning signs reviewed with patient/family; interpreter if used; barriers to follow-up and mitigation]