End-of-Therapy Treatment Summary (Pediatric Oncology)

(This is an End-of-Therapy Treatment Summary for a pediatric oncology patient. Do not include routine encounter elements such as review of systems or physical examination unless explicitly documented as part of a dual-purpose billed visit. Use unambiguous dates in YYYY-MM-DD format. If any required field is unknown, enter "Unknown" and document the gap in the Data Sources and Limitations section.)

Patient Name: [patient name]

MRN: [medical record number]

DOB: [YYYY-MM-DD]

Sex at Birth: [sex]

Primary Diagnosis: [plain-language diagnosis and formal terminology]

Treating Institution: [institution name]; [oncology team main contact and phone/email]

Author: [author name, role, YYYY-MM-DD signed]

Therapy Course Dates: [start date YYYY-MM-DD] to [end-of-therapy date YYYY-MM-DD]

Document Recipients: [PCP / survivorship clinic / family portal / other recipients]

Executive Summary

• [Diagnosis with stage/risk group and key biology] (Include classification system names.)
• [Relapse/progression history: none, or number with dates]
• [Therapy completion date and current disease status with date and modality of last evaluation]
• [Highest-risk exposures, e.g., cumulative anthracycline dose, chest/cranial radiation, transplant]
• [Major complications with lasting impact] (High-level only.)
• [Immediate next steps and timing of first follow-up]

Diagnosis and Initial Presentation

[Primary cancer type and subtype with histology]; diagnosed [YYYY-MM-DD]. [Primary site(s)] with [metastatic sites if any, or state no metastatic disease]. [Staging/risk group per classification system with version/year]. (Do not infer histology or stage from protocol assignment; document only confirmed findings or explicitly label as "presumed/treated as" with rationale.)

[Key pathology findings with accession number(s)] (Do not paste full reports.)

[Cytogenetic and molecular results influencing prognosis or surveillance] (Name assay, specimen, date.)

[Germline predisposition testing: performed/not performed; results and gene(s) if applicable, with date and lab]

[Major presenting complications and baseline organ dysfunction] (Only include factors that influenced therapy decisions.)

Disease Course Timeline

• [YYYY-MM-DD] – Diagnosis confirmed ([method: biopsy/cytology/other])
• [YYYY-MM-DD] – Start of frontline therapy ([protocol/regimen name and identifier if applicable])
• [YYYY-MM-DD] – [Response assessment milestone, e.g., end-induction] – [result/response category]
• [YYYY-MM-DD] – [Subsequent milestone, e.g., end-consolidation] – [result]
• (If relapse/progression occurred, include for each episode:)
  • [YYYY-MM-DD] – Relapse/progression at [site(s)]; [confirmatory testing]
  • [YYYY-MM-DD to YYYY-MM-DD] – Salvage therapy with [regimen] – [response achieved]
  • [Notable additional exposures introduced during salvage]
• [YYYY-MM-DD] – [Transplant or cellular therapy] (If applicable.)
• [YYYY-MM-DD] – Final end-of-therapy date
• [YYYY-MM-DD] – Last disease evaluation by [modality] – [status/response]

Antineoplastic Therapy Exposures

(This section is the source of truth for exposure-based survivorship care. Use generic drug names. For each cumulative dose, indicate verification status in Data Sources and Limitations.)

Systemic Therapy

(List all chemotherapy and systemic agents individually. If cumulative dose is unknown, state "cumulative dose unavailable" and cite the data gap.)

Agent	Route	Phase/Context	Date Range	Cumulative Dose (mg/m²)	Notes
[agent name]	[IV / PO / IT / IM / SQ]	[phase/context]	[YYYY-MM-DD to YYYY-MM-DD]	[value or "Unavailable"]	[dose reductions, delays, or deviations from protocol with reason]

Anthracycline Summary: [per-agent cumulative doses]; doxorubicin-equivalent total: [dose] mg/m²

Alkylating Agent Summary: [per-agent cumulative doses]; cyclophosphamide-equivalent dose (CED): [dose] mg/m² (If not tracked, state "CED not calculated.")

Intrathecal Therapy: [agent(s)], [number of doses], [date range]

Targeted/Immunotherapy: [agent and target], [duration or cumulative dose], [date range] (Include if applicable.)

Radiation Therapy

(Document each radiation course. Include key organ-at-risk doses if available and clinically meaningful.)

Site/Target	Modality	Technique	Total Dose (Gy)	Dose/Fraction (Gy)	# Fractions	Dates	Field Descriptor	Key OAR Doses
[site/target]	[photon / proton / electron]	[3D-CRT / IMRT / VMAT / other]	[total Gy]	[Gy per fraction]	[number]	[YYYY-MM-DD to YYYY-MM-DD]	[e.g., craniospinal, whole lung, mediastinal]	[e.g., mean heart dose] (If unavailable, state so.)

Surgery and Major Procedures

• [YYYY-MM-DD] – [Procedure type] – [site] – [key outcome, e.g., margin status, pathology accession #]

(Include diagnostic biopsies, definitive resections with margin status, limb-sparing or amputation procedures, organ resections, and device placements/removals.)

Hematopoietic Cell Transplant or Cellular Therapy

(Include only if performed.)

HSCT: [Autologous / Allogeneic] on [YYYY-MM-DD]; donor: [type/source]; conditioning: [regimen with agents and doses if available]; GVHD: [none, or acute/chronic with grade, organs involved, current status]

Cellular Therapy: [Product type/target] on [YYYY-MM-DD]; bridging therapy: [regimen]; acute toxicities: [CRS/ICANS grade and resolution status]

Major Complications During Therapy

(Include only complications with high clinical impact: required hospitalization/ICU, caused dose modification or therapy discontinuation, required invasive intervention, led to chronic conditions or ongoing specialty follow-up, or represent sentinel risks for late effects. Omit organ systems without significant complications.)

• [Organ system]: [complication], [YYYY-MM-DD to YYYY-MM-DD], [severity/context], [key interventions], [resolved / ongoing with sequelae]

(Relevant systems: infectious, hematologic/immune, cardiac, pulmonary, renal, hepatic, neurologic, endocrine, musculoskeletal, GI/nutrition, psychosocial if significant.)

Status at End of Therapy

• Disease status: [status] per [modality] on [YYYY-MM-DD]
• Functional status: [age-appropriate description]
• Active problems persisting post-therapy: [e.g., neuropathy, hearing loss, organ dysfunction with brief status]
• Indwelling devices: [device type, location, removal plan/timing]
• Current medications requiring continuity: [infection prophylaxis with intended stop date], [endocrine replacement], [anticoagulation], [other]
• Ongoing maintenance therapy: [regimen and expected duration] (If applicable; clarify what "end-of-therapy" refers to in this context.)

Surveillance Plan

(Provide actionable guidance. Do not infer surveillance intervals; if not finalized, state when the plan will be determined and provide interim safety-net instructions.)

Follow-up Schedule

Item	Timing	Responsible Service	Notes
Next oncology visit	[date or interval]	[oncology / survivorship / PCP]	[notes]
Visit frequency (next 6–24 months)	[interval]	[service]	[notes]

Relapse Surveillance

Modality	Frequency and Duration	Responsible Service	Notes
[labs / imaging / marrow / LP]	[interval and stop criteria]	[service]	[protocol name if applicable]

Symptoms requiring urgent evaluation: [red-flag symptoms specific to this diagnosis]

Exposure-Based Organ Surveillance

Test	Timing	Responsible Service	Exposure Rationale
[e.g., echocardiogram]	[date/interval]	[service]	[e.g., anthracycline cumulative dose]
[e.g., audiology]	[date/interval]	[service]	[e.g., platinum or cranial radiation exposure]

Supportive Care

Item	Plan	Responsible Service	Notes
Infection prophylaxis	[agents, duration, stop criteria]	[service]	[monitoring parameters]
Immunizations	[revaccination schedule/start date]	[service]	[next review date]
Device management	[planned removal date/criteria]	[service]	[notes]

Transition Planning

[Planned timing of transition to survivorship/late effects clinic]; [interim safety-net instructions if plan not finalized]

Care Coordination

Oncology team contacts: [names, roles, phone, email]; after-hours: [contact]

Recipients of this summary: [PCP, survivorship clinic, family portal, others]

Guidance for PCP:

• When to contact oncology urgently: [red-flag symptoms or findings]
• Oncology vs PCP responsibilities: [who orders surveillance, manages referrals, etc.]
• Precautions specific to this patient: [e.g., live vaccine timing, anthracycline re-exposure limits, contraindicated medications]

Data Sources and Limitations

Primary data sources: [EHR chemotherapy administration records, pharmacy records, radiation oncology summary, operative reports, outside records, pathology systems, patient/family report]

Known data gaps: [missing outside facility records, incomplete cumulative dose capture, uncertain dates, unavailable OAR doses, other]

Cumulative dose verification status:

• [Agent] – [Verified against administration records / Estimated (state method) / Unavailable]

(If any header field was entered as "Unknown," restate the missing element here with plan to obtain if applicable.)