Oncology Clinic Note (SOAP)

Visit Information

Visit Date: [date]

Provider: [clinician name and credentials]

Patient: [name, MRN, DOB]

Visit Type: [New Consult / New-to-You / Follow-up / Pre-cycle Clearance / Scan Review / Urgent Symptom]

Chief Concern

[One-line reason for visit in context of diagnosis and current/planned treatment]

Oncology Diagnosis Banner

• Primary cancer: [site/histology] (Use "pending" if unknown on new consults.)
• Stage at diagnosis: [staging system and stage; date] (Use "pending" if unknown.)
• Current disease status: [no evidence of disease / stable disease / responding / mixed response / progressing / unknown]
• Key biomarkers/molecular drivers: [marker — result; source/date] (Include only if therapeutically relevant; use "pending" if not yet resulted.)
• Current regimen: [regimen/agents] — [intent: curative / adjuvant / neoadjuvant / disease control / palliation], [line of therapy if metastatic], [cycle/day C#/D#]

Subjective

[Orienting statement: diagnosis, stage/status, current/planned treatment, purpose of today's visit] (Limit to 1–2 sentences.)

[Interval history since last visit or since diagnosis for new consults] (Chronological narrative including symptom changes, ED visits/admissions/procedures, regimen and cycle/day context, dose delays or modifications with reasons.)

• Toxicity review: [regimen-specific adverse effects with grade/severity and functional impact]
• Performance status: ECOG [0–4] (Note interval changes.)
• Oral therapy adherence: [adherence, missed doses, barriers] (Include only if on oral therapy.)
• Targeted ROS: [decision-relevant positives/negatives] (Include for new consults, regimen changes, immunotherapy visits, or high-risk symptoms; omit on stable routine follow-ups.)
• Patient goals/preferences: [goals/values influencing treatment choices] (Include only if relevant to decisions today; use direct quotes sparingly.)

Oncology History

(Include for New Consult or New-to-You visits; omit for established patients.)

• Diagnosis: [date] — [histology/grade]
• Staging at diagnosis: [staging system] — [stage; date]
• Key biomarkers: [marker, result, source, date]
• Prior treatments: [modality] — [procedure/regimen] — [dates] — [best response] — [reason stopped] (List each line of therapy.)

Medications and Allergies

• Current antineoplastics: [agents, route, schedule]
• Supportive care: [antiemetics, growth factors, antimicrobials, analgesics]
• Anticoagulants/antiplatelets: [agent and indication]
• OTC/herbals/supplements: [list or none reported]
• Allergies: [allergen — reaction type and severity; include infusion reaction history]

Objective

• Vitals: [BP, HR, RR, Temp, SpO2, weight with trend if significant, pain score]
• Performance status: ECOG [0–4]
• Exam: [pertinent positives and negatives relevant to decision-making]
• Labs: [date and key results] (Highlight values impacting hold parameters, dose adjustments, or toxicity.)
• Imaging: [modality, date, comparison point, response/progression findings] (Include criteria if used.)
• Pathology/Molecular: [specimen site/date, pertinent results] (Include only if decision-relevant today.)
• External records reviewed: [source and summary] (Include only if applicable.)

Assessment

[Oncologic synthesis: diagnosis, stage/current status, key biomarkers, current line of therapy and intent, response context with criteria if used, dominant toxicities/complications affecting today's decisions]

• Primary malignancy: [improving / stable / worsening / unknown] — [staging, response assessment with criteria and scan date, line of therapy, intent, supporting evidence]
• Treatment-related toxicities: [issue and grade] — [status and impact] (Omit if none active.)
• Cancer complications: [issue] — [status/severity] (Omit if none.)
• Relevant comorbidities: [condition] — [status] (Include only if affecting oncologic care.)
• Supportive care/psychosocial: [needs] — [status] (Include only if active concerns.)

(If information required for treatment decisions is missing, document the gap explicitly and plan to obtain.)

Plan

• Primary malignancy:
  • Systemic therapy: [regimen, cycle/day, dose modifications with reasons, supportive prophylaxis, hold criteria]
  • Rationale: [link to objective data and patient goals]
  • Monitoring: [labs with timing and hold parameters; imaging modality and interval; tumor markers if used]
• Toxicity management: [interventions for each active adverse effect, dose holds/reductions, supportive meds, monitoring timeline] (Omit if no active toxicities.)
• Cancer complications: [interventions, rationale, follow-up] (Omit if none.)
• Comorbidities: [management updates or coordination] (Include only if affecting oncologic care.)
• Supportive care: [pain, nutrition, psychosocial, palliative care involvement, education provided] (Include only if active needs.)
• Goals-of-care: [patient understanding, options discussed, patient values, resulting decisions, code status if addressed] (Include at major decision points or transitions between lines of therapy.)
• Fertility/pregnancy counseling: [discussion, contraception recommendations, referrals] (Include only for patients of reproductive potential on gonadotoxic/teratogenic therapy.)

Follow-up

• Next visit: [timing and purpose]
• Pre-visit requirements: [labs/imaging needed before next visit]
• Return precautions: [fever, uncontrolled symptoms, neurologic changes, dyspnea, bleeding]