Hematology Inpatient Progress Note

Date/Time: [Date and time of documentation]

Patient: [Name, MRN, DOB/Age]

Location: [Unit/Room], Hospital Day [#], Admitted [date]

Diagnosis: [Primary hematologic diagnosis]

Therapy Context: [Regimen/Cycle/Day if on protocol; transplant status if applicable]

Author: [Role and supervising attending]

Summary

[Age]-year-old [sex] with [hematologic diagnosis] admitted [admission date and reason], now hospital day [#], on [current therapy/regimen status], complicated by [1–3 active issues]. (Write 1–3 sentences. Emphasize what is different today; do not copy forward unchanged text without verification.)

Interval History

Events since last note: [Overnight/interval events including fevers with timestamps, bleeding episodes and severity, procedures, transfusions administered and response, antineoplastic or immunotherapy given, level of care changes, key occurrences] (If none, state: "No acute events overnight.")

Symptoms and trajectory: [Patient-reported symptoms and trends: bleeding/bruising, fatigue, dyspnea, pain, mucositis, GI symptoms, infectious symptoms, neuro symptoms relevant to cytopenias/coagulopathy; functional status changes relevant to disposition] (Focus on trends and changes, not static lists.)

Objective

Vitals: [Current T, HR, BP, RR, SpO2] ([24-hour ranges]). [Oxygen status]. (Include fever curve context for neutropenic patients.)

Exam: [Pertinent findings: general appearance, oral mucosa, cardiopulmonary, skin for petechiae/ecchymoses/catheter sites, lymph nodes, neuro if bleeding risk] (Document only what was performed; if limited or not performed, state explicitly.)

CBC Trend: (List today plus ≥2 prior values.)

• [Date]: WBC [ ], ANC [ ], Hgb [ ], Plt [ ] (Retic [ ] if relevant)
• [Date]: WBC [ ], ANC [ ], Hgb [ ], Plt [ ]
• [Date]: WBC [ ], ANC [ ], Hgb [ ], Plt [ ]

(Include smear findings only if reviewed and clinically relevant.)

Data: [Relevant chemistry/metabolic labs and trends; coagulation studies if indicated; TLS panel if monitored; hemolysis markers if relevant; microbiology with collection dates and pending/final status; new imaging or pathology with key impression—label preliminary vs final]

Therapies (last 24 hours): [Antineoplastic agents with day of regimen; growth factors; anticoagulation with indication; transfusions with product type and response; key supportive therapies]

Assessment & Plan

[1–3 sentence synthesis interpreting the course since yesterday: direction of count recovery or decline, fever status, transfusion requirements, treatment tolerance, and overall trajectory.]

(Present problems in order of clinical severity. For each problem, include: problem title with qualifier, assessment of current status with key supporting data, and plan including diagnostics, therapeutics, monitoring thresholds, and contingencies. Address hematology-specific concerns as applicable: primary diagnosis and treatment phase, cytopenias with transfusion thresholds, infection/neutropenic fever, bleeding/coagulopathy, anticoagulation, TLS risk, organ dysfunction affecting dosing.)

#1 [Problem title with qualifier]

Assessment: [Current status, pertinent data, interpretation, toxicity grading if applicable]

Plan: [Diagnostics, therapeutics, monitoring thresholds, contingencies]

#2 [Problem title with qualifier]

Assessment: [Current status, pertinent data, interpretation]

Plan: [Diagnostics, therapeutics, monitoring thresholds, contingencies]

#[n] [Additional problems as needed]

Assessment: [Current status, pertinent data, interpretation]

Plan: [Diagnostics, therapeutics, monitoring thresholds, contingencies]

VTE Prophylaxis: [pharmacologic / mechanical / contraindicated—specify agent if applicable]

Code Status: [Full / DNR / DNI / other] (Confirm and document date of discussion.)

Disposition: [Anticipated discharge date and destination; barriers and steps to resolve]