Inpatient Oncology Progress Note

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

Patient: [name, MRN, DOB/age, room]

Hospital Day: HD# [and POD# if post-operative]

Malignancy: [primary diagnosis, stage, treatment-driving molecular markers]

Treatment Status: [regimen name; cycle/day or transplant day; intent; active / on hold]

Code Status: [code status]

Lines/Access: [type, date placed, concerns if any]

Clinical Snapshot

[Single-sentence overview] (Begin with HD#. Summarize diagnosis, treatment phase, key active issues, and today's trajectory.)

Subjective

[Interval events and patient-reported symptoms] (Narrative paragraph: overnight/interval events including fever curve, hemodynamic changes, oxygen needs, transfusions, procedures; then patient-reported symptoms including pain with severity, mucositis, nausea/vomiting, diarrhea, dyspnea, bleeding, neurologic symptoms; functional status including PO intake, ambulation, sleep. Document targeted negatives relevant to today's differential. If patient cannot provide history, note the limitation and alternate source.)

Objective

Vitals: [Tmax, Tcurrent, HR, BP, RR, SpO2 with O2 delivery]

I/Os/Weight: [intake, output, net balance, weight] (Include when relevant to TLS risk, AKI, or fluid management.)

Exam: [General appearance; oropharynx for mucositis/thrush; skin for rash/petechiae; line/port sites for erythema/tenderness/drainage; neuro for orientation/delirium; other pertinent findings by system]

Labs: [CBC with ANC, chemistries, and other pertinent values with trends in parentheses] (Include TLS panel, LFTs, or coags only when clinically indicated. Present only values relevant to active problems.)

Micro: [Blood culture status by source; other cultures with pending/final status; susceptibilities if actionable]

Imaging/Studies: [New results only with date and one-line interpretation] (Omit if none.)

Active Therapies: [Antimicrobials with start date and stop criteria; prophylaxis; steroids with indication; G-CSF if used; anticoagulation with platelet-aware plan]

Assessment & Plan

[Summary statement] (1–2 sentences on current trajectory, primary risks, and overall clinical direction.)

(Organize by problem, prioritized by clinical severity. For each active problem, include status, brief assessment, plan with monitoring, and contingencies. Include only problems that are active today.)

[Malignancy / Cancer-Directed Therapy]

[Status, regimen, response indicators, toxicity attribution, dose modifications] (Include only if active.)

Plan: [therapy continuation/modification; monitoring; next response assessment; multidisciplinary coordination]

[Cytopenias]

[ANC trend, transfusion dependence, bleeding risk] (Include only if active.)

Plan: [transfusion thresholds; growth factor use; VTE prophylaxis adjusted per platelets; monitoring frequency]

[Infection / Febrile Neutropenia]

[Fever curve, suspected source, culture status, risk stratification] (Include only if active.)

Plan: [antimicrobials with de-escalation criteria; source control; prophylaxis; monitoring checkpoints]

[Treatment Toxicities]

[Active toxicities with severity, attribution, impact on therapy] (Include only if active.)

Plan: [management; dose modifications; monitoring parameters]

[Supportive Care]

[Pain, nutrition, electrolytes, TLS prevention, mucositis, GI symptoms, rehab needs] (Include only if active issues.)

Plan: [analgesia; antiemetics; electrolyte repletion; VTE prophylaxis with platelet-aware approach; PT/OT; psychosocial support]

[Discharge Readiness]

[Anticipated date or barriers; criteria: afebrile interval, ANC recovery, oral tolerance, outpatient antimicrobial plan, follow-up] (Include when discharge is being considered.)

Plan: [steps to meet criteria; home services; neutropenic precaution education; follow-up scheduling]

(Include only problem sections that are active today. If pending results will change management, note what is pending and the decision that depends on it.)