Oncology Discharge Summary

Patient: [Full name] | MRN: [MRN] | DOB: [DOB] | Sex: [Sex]

Allergies: [Allergy list / NKDA]

Admission Date/Time: [Admission date and time] | Discharge Date/Time: [Discharge date and time] | LOS: [Length of stay]

Discharging Service: [Service]

Attending Physician: [Name, credentials] | Primary Oncologist: [Name / Unknown] | PCP: [Name / Unknown]

Disposition: [home / SNF / hospice / acute transfer / expired / AMA]

Code Status: [Full code / DNR / DNI / DNR-DNI / other]

One-Line Summary

[Single-sentence summary: cancer diagnosis and therapy status; reason for admission; key intervention; outcome; disposition and key follow-up]

Reason for Hospitalization

[Presenting symptom or event triggering admission. Oncologic context: cancer diagnosis, histology, stage/status, current therapy and timing, immunosuppression level, central line presence and type. Key admission severity markers: hemodynamics, ANC, critical labs, initial imaging findings.] (3–6 lines; do not reproduce full H&P.)

Discharge Diagnoses

• [Principal diagnosis leading to hospitalization]
• [Cancer diagnosis with site, histology, and stage/status]
• [Secondary diagnoses]
• [Treatment-related diagnoses, labeled as such]
• [Complications during hospitalization]

(List principal diagnosis first. For suspected vs confirmed diagnoses, reference Pending Results section. State "suspected" or "confirmed" when relevant.)

Significant Findings

(Include only if results affect post-discharge management; omit entire section if none.)

• Labs: [Nadir counts, peak creatinine, LFT trends, tumor lysis markers, transfusion requirements]
• Microbiology: [Positive cultures with susceptibilities; relevant viral studies]
• Imaging: [Actionable findings: new metastases, PE, obstruction, cord compression, intracranial findings]
• Pathology/Molecular: [Results that returned during admission and informed decisions]

Procedures and Treatments

• [Date]: [Procedure or treatment with indication and key details]
• [Inpatient antineoplastic therapy: regimen, cycle/day, dates, any dose modifications with rationale]
• [Outpatient antineoplastic therapy status: held / continued / discontinued with rationale]

(Include biopsies, line placements/removals, paracentesis/thoracentesis, endoscopy, surgery, radiation fractions, transfusions, growth factors. If none, state: "No procedures performed during this admission.")

Hospital Course

(Problem-oriented format ordered by clinical severity and oncology relevance. For each problem include: assessment/etiology, key diagnostics, treatments and response, status at discharge, and post-discharge actions with responsible party.)

[Problem name]

[Assessment and etiology. Key diagnostic findings.]

• Treatment and response: [Therapies provided and clinical/laboratory response]
• Status at discharge: [Current stability and control]
• Post-discharge actions: [Action items and responsible party]

(Repeat problem subheadings as needed. Address: primary admission problem, active oncologic issues, treatment-related toxicities, major comorbidities affecting discharge. Include oncology-specific elements as applicable: antineoplastic therapy status with rationale for continuation/hold/discontinuation; immune-related adverse events with workup and steroid taper plan; VTE evaluation, treatment, and planned duration; pain management changes with bowel regimen and naloxone if prescribed; central line status and infection workup results. Document rationale for major medication changes.)

Complications and Adverse Events

(Include only if complications occurred during admission; otherwise omit this section.)

• [Event] → [Management] → [Residual risk or future precautions]

Condition at Discharge

[Clinical stability: symptom control, vital signs, oxygen requirements, functional status compared to baseline, cognitive status if relevant to adherence. Go/no-go factors for resuming outpatient therapy: count recovery, renal function, performance status. Status of lines, drains, or devices with care requirements.]

(For AMA discharge: explicitly label and document safety counseling provided. For death: state "Expired" with brief circumstances.)

Discharge Disposition and Services

Destination: [Home / SNF / hospice / acute transfer to specific facility]

Home Services: [Home health / PT / OT / infusion services / none]

DME: [Oxygen with flow rate / other equipment / none]

Support: [Primary caregiver and contact; identified barriers if relevant]

Discharge Medications

Changes from Admission

• Started: [New medications with dose, route, frequency, indication]
• Stopped: [Discontinued medications with rationale]
• Changed: [Dose or frequency changes with rationale]

Complete Discharge Medication List

• [Medication name] — [dose, route, frequency] — [indication] — [special instructions]

(Flag high-risk medications: anticoagulants, opioids, insulin, steroids, antimicrobials, oral antineoplastics. For antineoplastic therapy, state continue/hold/start with specific timing. Include supportive medications: antiemetics, antimicrobial prophylaxis, G-CSF schedule, bowel regimen. For steroid tapers, include exact schedule. Document rationale when home medications are intentionally not resumed.)

Follow-Up Appointments and Monitoring

1. [Clinic/service]: [Clinician] — [Date/time or timeframe] — [Purpose] — [Prerequisites: labs or imaging before visit]
2. [Infusion center]: [Regimen, cycle/day] — [Date] — [Pre-treatment lab timing]
3. [Additional follow-up as needed]

(Order by urgency. Oncology clinic follow-up typically within 3–14 days based on acuity. Include rescheduling instructions or alternate contact.)

Pending Results

• Test: [Name] | Date Sent: [Date] | Responsible Clinician: [Name/service] | Notification Plan: [How and when patient will be contacted] | Expected Action: [Decision pending on result]

(If none, state: "No pending results." Common oncology items: final cultures, fungal studies, cytology, surgical pathology, molecular profiling, flow cytometry.)

Patient Education and Return Precautions

• Education provided: [Topics covered; understanding confirmed or barriers identified]
• When to seek urgent care: Fever ≥[threshold], uncontrolled pain, bleeding, dyspnea, new neurologic symptoms, signs of dehydration, or other concerning symptoms
• 24/7 oncology contact: Daytime: [clinic number] | After-hours: [on-call pathway]
• Key medication instructions: [Emphasis on changes and high-risk medications]
• Immunocompromised precautions: [Neutropenia and infection avoidance guidance if applicable]

(Note if interpreter was used and language.)

Goals of Care

[Treatment intent: curative / palliative / not yet determined. Advance directive status. Hospice considerations if discussed. Plan for ongoing goals-of-care conversations and responsible clinician.]

(Include only if goals-of-care discussions occurred or are relevant to discharge planning; otherwise omit this section.)

Authentication

Discharging Clinician: [Signature, credentials, date/time]

Attending Physician: [Signature, credentials, date/time]