Inpatient Oncology Consultation Note

Date/Time of Evaluation: [Date and time of bedside/telehealth evaluation]

Date/Time of Note Entry: [Date and time of documentation] (Include only if different from evaluation time)

Author: [Name, degree(s), role]

Patient Location: [Unit/room]

Requesting Service/Clinician: [Service and clinician name]

Consult Question(s): [Verbatim consult question(s)] (If multiple, list in descending urgency)

Urgency: [routine / urgent / emergent] — [brief justification]

Consult Scope: [recommendations only / co-management / oncology assuming primary for malignancy-related issues]

Oncology Snapshot

[2–4 sentence executive summary including: patient age and key comorbidities affecting oncologic decisions; malignancy status (confirmed vs. suspected) with primary site and stage if known; reason for admission and consult trigger; one-sentence bottom line with highest-priority concern or immediate recommendation]

History

Chief Concern: [Restated consult task in one line]

History of Present Illness and Hospital Course: [Coherent, time-anchored narrative leading to oncology involvement including symptom onset/trajectory, red flags, admission diagnosis, key hospital events by date, pertinent treatments already given, and pertinent positives/negatives related to oncologic emergencies] (Use brief bullets below for complex courses; include direct patient quotes only when they materially affect care decisions)

• [Date]: [Key event or change in status]
• [Date]: [Key diagnostic/treatment milestone]
• [Date]: [Response/toxicity/complication]

Oncologic History Synthesis:

• Working Diagnosis: [confirmed / suspected / unknown] [Primary site] (Basis: [pathology / imaging / clinical syndrome])
• Histology and Grade: [Histology and grade / pending / unknown] (Source: [biopsy/cytology site and date])
• Biomarkers/Molecular: [Actionable markers / none detected / pending / unknown] (Include only markers relevant to immediate decisions)
• Pathology Status: [final / preliminary / pending] (Pending studies: [IHC / FISH / NGS / other])
• Staging Summary: [Stage / presumed / incomplete / unknown] (Based on: [study and date]; Needed to confirm: [tests/imaging])
• Sites of Disease of High Clinical Impact: [Clinically significant sites with burden description]
• Prior Cancer-Directed Therapy:
  • Surgery: [Site/procedure, date, margins / none]
  • Radiation: [Site(s), dose/fractions, dates / none]
  • Systemic Therapy: [Regimen name(s), line(s), start–stop dates, best response, reason stopped, notable toxicities / none]
  • Last Treatment Date: [Date / unknown]
• Outpatient Oncologist/Institution: [Name(s) and center / none / unknown] (Records: [available in chart / outside records requested on date])

Relevant Medical History:

• Comorbidities Impacting Decisions: [Cardiac function/EF, autoimmune disease, hepatitis/HIV status, baseline neuropathy, VTE history, renal/hepatic disease, other decision-modifying conditions]
• Medications: [Current medications] (Emphasize anticoagulants, immunosuppressants, QT-prolonging agents, prior infusion reactions)
• Allergies: [Drug and reaction / NKDA]
• Family History: [Relevant syndromic history / none] (Include only if syndromic concern exists)
• Social History: [Tobacco/alcohol/substance use, housing, caregiver support, occupational exposures if relevant]
• Functional Status: [ECOG 0–4 / KPS 0–100] — [Plain-language description of ADLs and recent functional decline]

Objective

Vitals and Weight:

• T: [temp], HR: [rate], BP: [pressure], RR: [rate], SpO2: [saturation] on [O2 delivery]
• Weight: [kg] ([stable / increased / decreased] from [baseline/admission])
• Central Access: [PICC / port / tunneled line / PIV only / none] — [Line status: functional / concerns]

Physical Exam: (Focused and relevant to consult question; avoid autopopulated normals)

• General/Mentation: [Appearance, distress level, orientation]
• Targeted Findings: [System-focused findings relevant to consult question: neuro if CNS/cord concern; volume status if TLS/renal/hypercalcemia; skin/oral if mucositis or immune toxicity; lymph nodes if affects differential or biopsy planning]

Data Review: (Present selectively; include dates and trends; document unavailable data explicitly with request status)

• Labs: [CBC with ANC trend, CMP with creatinine and calcium, LFTs, coagulation, tumor lysis labs if relevant, other pertinent values] (Include transfusion history if relevant)
• Microbiology: [Culture results with dates, current antimicrobial coverage, pending studies] (Include only if infection or neutropenia is relevant)
• Imaging: [Modality, date] — [Key findings with your interpretation when management-changing]
• Pathology/Cytology: [Specimen source and date] — [Summary of results and components pending]
• Other Studies: [EKG/echo if therapy selection depends on cardiac status, pregnancy test if applicable, other decision-relevant tests]

Assessment and Recommendations

Assessment: [2–4 sentence synthesis integrating malignancy status (confirmed/suspected), current clinical stability, highest-risk oncologic complications, and treatment intent (curative vs. palliative) if discussed]

Problem List: (Organize by acuity and impact; life/organ-threatening first)

[Problem 1 Name and Status]

Reasoning:

• [Key supporting data with dates]
• [Additional supporting data]
• [Differential diagnosis if it changes next steps]

Recommendations:

• Diagnostics: [Test, timing, purpose]
• Therapeutics: [Drug/dose/route/schedule or non-pharmacologic interventions]
• Monitoring: [Parameters to trend, frequency, toxicity surveillance]
• Consults/Coordination: [Service and rationale]
• Disposition: [Inpatient milestones required before discharge, outpatient timeline]
• Contingency: If [X], then [Y]

[Problem 2 Name and Status]

(Repeat structure for additional problems as needed)

Communication: [When and to whom recommendations were communicated, including clinician name and role] (Specifically document communication of urgent items)

Ownership: [What oncology will follow vs. what primary team will execute]

Antineoplastic Therapy Plan

(Include only when recommending inpatient chemotherapy, immunotherapy, targeted therapy, or urgent cancer-directed procedures; otherwise omit entire section)

• Treatment Intent: [curative / disease-control / symptom palliation / bridge-to-definitive] — [Rationale for inpatient delivery]
• Regimen: [Name, components, cycle/day, route, planned start date] (Include dosing basis, dose adjustments, and planned supportive medications)
• Preconditions: [Consent status, patient education status, required baseline assessments (labs, organ function, pregnancy status, infection screen, cardiac assessment), access readiness]
• Monitoring and Hold Parameters: [What to monitor during/after administration; specific hold/stop criteria for fever, hypotension, lab thresholds, suspected hypersensitivity]

Goals of Care

(Include when new metastatic/incurable cancer is diagnosed or suspected, when major escalation decisions are at hand, or when patient values influence the plan; otherwise omit entire section)

[Patient understanding of diagnosis as assessed; expressed preferences and unacceptable outcomes; surrogate decision-maker and code status if addressed or deferral with rationale; whether palliative care was recommended or consulted] (Use short narrative with selective direct quotes when they reflect meaningful patient/family values)

Disposition and Follow-Up

Inpatient Follow-Up: [Oncology will follow: daily / intermittently / sign off after these recommendations] (Specify conditions for re-consult if signing off)

Outpatient Follow-Up: [Target timing for outpatient oncology appointment; named clinic/team or plan for referral]

Pending Results: [Critical pending results (pathology, molecular, imaging) with responsible party for follow-up and plan to communicate results to patient and outpatient oncologist]

Signature

[Author name], [Credentials] — [Service] — [Contact information]