Inpatient Daily Progress Note (Pediatric Oncology)

Date/Time: [Date and time of note entry]

Author/Service: [Author name and role / Service]

Attending: [Attending physician]

Patient: [Full name], MRN: [MRN]

Hospital Day (HD#): [Hospital day number]

Diagnosis: [Primary pediatric oncologic diagnosis] — [new diagnosis / relapse / remission / post-HSCT day #]

Treatment Status: Protocol/Regimen: [Name or "Not verified"]; Cycle/Course/Block/Day: [Details or "Not verified"]; Chemotherapy today: [due / held / none] [If held: reason]. (If no active antineoplastic therapy, state: "Antineoplastic therapy today: None.")

Interval Summary

[2–5 line synopsis: reason for admission; major interval events since last note; current clinical trajectory: [improving / stable / worsening]; top risks for next 24 hours] (Avoid copy-forwarded text or detailed lab dumps.)

Subjective

• [Overnight events reported by patient/family/nursing] (If none: "No new symptoms reported.")
• [Therapy tolerance: nausea, vomiting, oral intake, mucositis, pain, diarrhea, respiratory symptoms, neurologic changes]
• [Pain/symptom control status and PRN use trends]
• [Pediatric observations: activity level, interaction, caregiver concerns]

(If patient unavailable, note limitation and information source.)

Objective

Vitals (24h): Tmax [value]; HR [value]; BP [value]; SpO2 [value] on [device]; Pain [score]; Weight [value] ([change vs prior])

I/O (24h): In [total] / Out [total] / Net [mL]; UOP [mL/kg/hr] (Include UOP when relevant to hydration or TLS monitoring.)

Exam: [General appearance and perfusion]; [HEENT including mucositis]; [Respiratory]; [Cardiovascular]; [Abdomen]; [Skin for bruising/petechiae/bleeding]; [Neurologic]; [Line sites] (Document pertinent positives and relevant negatives tied to current risks. Do not infer negative findings unless explicitly assessed.)

Data: [CBC with ANC and trend]; [Chemistries and TLS parameters as relevant]; [Coags if indicated]; [Microbiology results and pending cultures with timing]; [Drug levels if applicable]; [Recent imaging/procedures] (Use placeholders for pending results with expected timing.)

Lines/Access: [Line type and location]; Function: [working / won't draw / other]; Site: [appearance]; Necessity: [one-line justification] (If no central access, state explicitly.)

Antineoplastic Therapy

• Last 24h: [Agents administered with timing; interruptions or reactions] (State "None" if none.)
• Due today: [Agents with timing; pre-therapy requirements] — [Proceed / Hold] (If held, state explicit reason.)
• Dose modifications: [Changes and rationale: toxicity, lab threshold, protocol rule] (State "None" if none.)
• Monitoring today: [TLS labs frequency; urine pH goal; neuro checks; other protocol-mandated monitoring]

Assessment & Plan

(Order problems by severity: life-threatening issues first, then active therapy, infection/febrile neutropenia, cytopenias/transfusions, toxicities/supportive care, and disposition. For each problem: 1–2 line assessment with status and trajectory, then bulleted plan.)

[Problem 1]

[Assessment: current status, trajectory, key concerns]

• [Diagnostics, therapeutics, monitoring with frequency, consults, contingency actions]

[Problem – Infection/Febrile Neutropenia]

[Assessment: febrile status, ANC, hemodynamics, suspected source, culture status]

• Antimicrobials: [Agent] — [indication]; started [date], day [#]; stop/de-escalate when [criteria] (If none: "No systemic antimicrobials.")
• [Diagnostics, monitoring, infection control precautions, escalation criteria]

[Problem – Cytopenias/Transfusions]

[Assessment: count trends, bleeding risk, prior transfusion responses]

• Last 24h: [Products given, indications, reactions]
• Today: RBC: [Yes / No] — [threshold/rationale]; Platelets: [Yes / No] — [threshold/rationale]
• [Product requirements: irradiated / leukocyte-reduced / CMV-safe / premedications]

[Problem – Toxicities/Supportive Care]

[Assessment: symptom burden with grading if required by protocol (CTCAE v5 or v6 per protocol)]

• [Analgesia, antiemetics, mucositis care, bowel regimen]
• [Hydration/nutrition: IVFs, TPN, enteral feeds, diet]
• [VTE prophylaxis, rehabilitation, psychosocial supports]

[Problem – Disposition]

[Assessment: discharge readiness, anticipated timeline, barriers]

• [Afebrile duration; culture status; oral intake adequate; pain controlled on home regimen; antimicrobial transition plan; line care teaching; follow-up scheduled]
• (If not discharge-ready: "Not discharge-ready — [brief reason]")

Author: [Name, credentials]

Signed: [Date/Time]