Inpatient Admission H&P (Pediatric Oncology)

Patient: [Name / MRN]

DOB/Age: [DOB / Age]

Sex: [Sex]

Date/Time of Encounter: [Date / Time]

Admission Date/Time: [Date / Time]

Location: [Unit / Room]

Attending: [Attending Physician]

Service: [Service / Team]

Author/Role: [Name / Credentials / Role]

Historian(s): [Patient / Parent(s) / Caregiver(s) / Medical record / Outside provider] (Include reliability assessment and interpreter use if applicable.)

Admission Type: [Planned Chemotherapy / Unplanned Admission] (If transferred, note referring facility and reason.)

Guardian/Consent Authority: [Name / Relationship] — Present for consent: [yes / no]

Chief Concern

[Primary reason for admission with oncology context] (One to two lines. For planned chemotherapy: include protocol name, cycle, and day. For unplanned admissions: state the acute presentation.)

History of Present Illness

[Oncology context paragraph] (Open by stating underlying diagnosis, current treatment phase, and key timing. Attribute sources: per parent, per patient, per chart, per outside hospital note. Anchor time-dependent statements to actual dates/times.)

[Presenting concern narrative] (Describe onset, timeline, evolution, severity, associated symptoms, pertinent negatives, sick contacts, home interventions, and functional status changes.)

(For planned chemotherapy admissions, include interval history:) [Events since last cycle: febrile episodes, infections, transfusions, ED/hospital visits, dose delays or modifications with reasons, toxicities, current treatment parameters met or pending]

(For unplanned admissions, include ED or outside hospital course:) [Interventions performed, antimicrobials given with timing, cultures obtained, imaging results, clinical trajectory, current stability, differential diagnosis]

Oncologic History

• Diagnosis: [Cancer type/subtype] — [Initial stage/risk category] — [Current disease status: newly diagnosed / remission / relapse / refractory] — [Date of diagnosis] — [Key pathology/molecular markers]
• Treatment Summary:
  • [Current protocol/regimen; cycle/day at admission]
  • [Prior chemotherapy agents with cumulative toxicity relevance; state "Unknown" if cumulative doses unavailable]
  • [Radiation history: sites and approximate dates]
  • [Relevant surgical history]
  • [HSCT/CAR-T history if applicable: type, date, complications]
• Toxicity Risk Profile:
  • [Cardiac risk: anthracycline exposure, most recent echo date/result if relevant]
  • [Renal baseline and nephrotoxin sensitivities]
  • [Hepatic baseline]
  • [Neurotoxicity history; seizure history]
  • [Ototoxicity concerns]
  • [Prior severe mucositis or GI complications]
  • [Thrombotic history]
  • [Drug hypersensitivity history and management plan]
  • [Tumor lysis syndrome risk level and prophylaxis plan if applicable]
  • (Include fertility considerations only if clinically applicable.)

Past Medical and Surgical History

• Non-oncologic medical conditions: [Conditions]
• Surgical/procedural history: [Procedures with dates; include central line placements/removals]
• Birth/developmental history: [Key details] (Include for infants/young children when relevant to assessment.)

Medications

Reconciliation source(s): [Caregiver report / Pharmacy records / Prior discharge summary] (If incomplete, state "Pending pharmacy reconciliation.")

• [Medication] — [Dose] [Route] [Frequency] — [Indication] — Last taken: [date/time if relevant] (Flag high-risk medications: anticoagulants, immunosuppressants, seizure medications, steroids, opioids.)

(For planned chemotherapy admissions, document supportive care context:)

• Antiemetic plan: [Agents and schedule based on regimen emetogenicity]
• Antimicrobial prophylaxis: [PJP / Antiviral / Antifungal as applicable]
• Growth factor plan: [Agent/timing if applicable]
• Hydration/electrolyte plan: [Type/rate/additives]

Allergies and Adverse Reactions

• [Agent] — [Reaction type/severity] — [Date] (Include chemotherapy hypersensitivity history with premeds used and desensitization/ICU monitoring requirements.)
• [Transfusion reactions: type and management]
• [Latex/chlorhexidine/adhesive reactions relevant to line care]

Social History

• Caregivers/consent: [Primary caregivers; custody considerations]
• Housing/transportation: [Stability; transportation for follow-up]
• School/daycare: [Enrollment status; accommodations]
• Language/health literacy: [Preferred language; interpreter needs]
• Environmental exposures: [Tobacco smoke; pets; travel; sick contacts]
• Barriers/supports: [Financial/logistical barriers; social work involvement] (If SDOH screening not completed, note as pending.)

Review of Systems

(Use toxicity-focused ROS for planned chemotherapy; problem-focused ROS for unplanned admissions. If limited due to age/acuity, document reason.)

• Constitutional: [Fever; fatigue; weight change]
• Oral: [Mouth sores; mucositis]
• Respiratory: [Cough; dyspnea]
• Cardiovascular: [Chest pain; palpitations]
• Gastrointestinal: [Nausea; vomiting; diarrhea; abdominal pain; oral intake]
• Genitourinary: [Dysuria; urine output]
• Skin: [Rash; bruising; bleeding]
• Neurologic: [Headache; mental status changes; neuropathy]
• Line site: [Pain; swelling; drainage]

Physical Examination

• Vitals: Temp [value] | HR [value] | RR [value] | BP [value] | SpO2 [value] | Pain [score with scale]
• Anthropometrics: Ht [cm] | Wt [kg] | BSA [m² if applicable] | Dosing weight: [actual / adjusted] | I/Os: [if available]
• General: [Appearance; well-appearing vs ill-appearing; toxicity assessment]
• HEENT: [Mucositis grade if present; hydration status; oropharynx]
• Cardiovascular: [Heart sounds; rate/rhythm; perfusion]
• Respiratory: [Work of breathing; breath sounds]
• Abdomen: [Soft/tenderness; organomegaly; bowel sounds]
• Skin: [Petechiae; bruising; rash; extravasation concerns]
• Neurologic: [Mental status; focal deficits; gait if applicable]
• Lines and Access: [Type: port / PICC / tunneled / peripheral IV] — [Lumens] — [Site condition: erythema, tenderness, drainage, dressing integrity] — [Function: last successful flush/blood draw; occlusion history] — [Access restrictions] (If details pending verification, state explicitly.)

Data Review

• Labs: [CBC with diff highlighting ANC/platelets] [CMP with renal/hepatic function] [TLS labs if applicable: uric acid, phosphorus, LDH] [Coagulation studies if relevant] [Culture/virology results with collection times] (Summarize significant results; include date/time.)
• Imaging: [Study type; date; key findings]

Assessment and Plan

(Problem-oriented format ordered by acuity. For each problem: 1–3 sentence assessment followed by bulleted plan.)

Primary Malignancy and Treatment Phase

[Diagnosis; current disease status; protocol context; admission goal]

• (For planned chemotherapy:) [Regimen, protocol, cycle/day] — Dosing basis: [height/weight/BSA with values] — [Dose modifications and rationale] — Premeds: [agents] — Hydration: [plan] — Monitoring: [lab frequency, vitals, neuro checks if indicated] — Hold parameters: [explicit criteria] — Consent/assent: [documented / pending]
• (If criteria pending:) [Specific results pending and contingency plan]

(Include additional problems as clinically indicated. Examples below:)

Fever / Neutropenia / Suspected Infection

[Risk stratification; differential diagnosis]

• [Cultures obtained with sites/times; empiric antibiotics with timing; hemodynamic goals; reassessment plan]

Tumor Lysis Syndrome Risk

[Risk level; current labs]

• [Prophylaxis: hydration, allopurinol/rasburicase] [Monitoring frequency] [Escalation triggers]

Cytopenias

[Etiology; bleeding risk]

• [Transfusion thresholds per institutional policy; product specifications; bleeding precautions]

Pain

[Etiology; severity]

• [Multimodal plan; opioid regimen with monitoring; bowel regimen]

Nausea / Nutrition

[Appetite and intake status]

• [Antiemetic plan; diet order; dietitian consult if indicated]

Line Management

[Access needs; infection prevention]

• [Access plan; dressing schedule; declotting if needed; line culture indications]

Psychosocial Needs

[Family coping; barriers identified]

• [Social work/child life; caregiver education; resources]

Disposition

• LOS drivers: [Key factors determining length of stay]
• Discharge criteria: [Objective criteria; home supports needed]
• Follow-up: [Next appointment or treatment milestone]

Chemotherapy Safety Documentation

(For planned chemotherapy admissions. Mark each: [Verified / Pending / N/A])

• Two patient identifiers confirmed: [Verified / Pending / N/A]
• Height/weight measured in metric; dosing weight confirmed: [Verified / Pending / N/A]
• Regimen and protocol with cycle/day confirmed: [Verified / Pending / N/A]
• Dose calculation reviewed: [Verified / Pending / N/A]
• Allergies and infusion reaction history reviewed: [Verified / Pending / N/A]
• Supportive care medications ordered: [Verified / Pending / N/A]
• Hold parameters reviewed: [Verified / Pending / N/A]
• Consent and assent documented: [Verified / Pending / N/A]
• Pregnancy assessment if applicable: [Verified / Pending / N/A]
• Medication reconciliation completed: [Verified / Pending / N/A]

(When information is missing: use "Unknown - not available" if source attempts documented; "Not assessed" only if intentionally deferred; "Unable to obtain - [reason]" if clinical status prevented collection. Do not autopopulate normal values or document consent/parameters as met unless verified.)