Oncology New Patient Consultation Note

Date of Service: [Date]

Location: [Clinic or facility name]

Provider: [Name, credentials]

Patient: [Full name, MRN, DOB]

Referral Source: [Referring clinician/service and contact]

Reason for Consultation: [Referral indication]

Information Sources: [Patient / family / outside records / care team] (Document who provided history and any limitations to reliability; distinguish patient report from outside records.)

Chief Complaint

[Patient-stated concern in one line, or referral intent for asymptomatic referrals]

Cancer Summary

Working Diagnosis: [Primary site, histology, grade; presumed vs confirmed]

Date of Diagnosis: [Date] ([Basis: biopsy site/method])

Stage: [Staging system] [clinical / pathologic / post-therapy] [TNM or disease-specific stage] [Stage group]

Disease Status: [newly diagnosed localized / locally advanced / metastatic / recurrent]

Key Biomarkers: [Actionable alterations first; test type, specimen source, date; pertinent negatives when decision-relevant]

Performance Status: ECOG [0–4] ([Functional description])

Treatment Intent: [curative / disease control / palliative] ([Planned modality sequence])

Prior Cancer Therapies: [Regimen(s), dates, best response] (If none, state none known.)

Active Complications: [Oncologic emergencies or urgent issues, if any]

(For unknown pivotal elements, mark as Pending with next action to obtain.)

History of Present Illness

[Narrative describing how malignancy was discovered, current symptoms and severity, key diagnostic steps with dates, emergent interventions performed, and patient's understanding, goals, and concerns]

(Clearly attribute information: patient-reported vs outside records vs clinician assessment.)

Oncology Timeline:

• [Date] – [Event] – [Key findings]
• (Add additional dated entries for salient events from outside records.)

Past Medical and Surgical History

Past Medical History:

• [Therapy-relevant comorbidities: cardiovascular, renal, hepatic, autoimmune, metabolic, neuropathy]
• [Prior malignancies: diagnosis, treatment, current status]
• (If history unknown or limited, document explicitly with reason.)

Past Surgical History:

• [Surgeries relevant to treatment planning: resections, transplants, devices, anatomic alterations]

Medications and Allergies

Current Medications:

• [Medication list with dose, route, frequency] (Highlight anticoagulants, steroids, immunosuppressants, QT-prolonging agents, supplements.)

Allergies: [Agent – reaction type] (Distinguish intolerance from anaphylaxis.)

Tobacco History: [never / former / current]; [pack-years]; [quit date if applicable]

Family History and Hereditary Risk

• [Cancer-affected relatives: relationship, cancer type, age at diagnosis, lineage]
• [Known familial pathogenic variants or prior genetic testing in patient/relatives]
• (If adopted or family history unknown, document explicitly.)

Social History

• Living Situation: [Household composition, caregiver availability]
• Functional Baseline: [ADLs, mobility, ambulatory aids]
• Employment: [Work status, leave needs]
• Social Determinants: [Transportation, financial concerns, other barriers]
• Substances: [Alcohol, cannabis, other substance use]

Review of Systems

• Constitutional: [Fatigue, weight change, fevers, night sweats]
• Pain: [Location, severity, pattern]
• GI: [Appetite, nausea, bowel changes, bleeding]
• GU: [Dysuria, hematuria, incontinence]
• Respiratory: [Cough, dyspnea, chest discomfort]
• Neurologic: [Headache, focal deficits, seizures]
• Hematologic: [Bruising, bleeding, infections]

(Keep focused on cancer-relevant symptoms; avoid comprehensive all-systems-negative blocks.)

Physical Examination

Vitals: [BP, HR, RR, Temp, SpO2, Weight]

General: [Appearance, distress level, nutritional status]

HEENT: [Pertinent findings]

Cardiovascular: [Rate, rhythm, murmurs, edema]

Respiratory: [Effort, breath sounds]

Abdomen: [Tenderness, masses, organomegaly]

Extremities: [Edema, tenderness, skin changes]

Lymph Nodes: [Cervical, axillary, inguinal findings]

Neurologic: [Mental status, focal deficits, gait]

Access Devices: [Line/port site appearance] (If present.)

Performance Status: ECOG [0–4]: [Functional justification]

Diagnostics Reviewed

Laboratory:

• [Date – test panel – key abnormalities and trends]

Pathology:

• [Specimen site, date, histology, grade, key IHC, margins/nodes if surgical]
• (Note if outside pathology review pending.)

Imaging:

• [Modality, date, body region, key staging/resectability findings]

Molecular/Biomarkers:

• [Test type, specimen source and date, actionable results, pertinent negatives, VUS labeled]

Pending/Missing: [Items not yet available; expected turnaround; plan to obtain]

Staging and Risk Stratification

Staging System: [System and version]

Classification: [clinical / pathologic / post-therapy]

Stage Values: [TNM values or disease-specific schema]

Stage Group: [Overall stage]

Prognostic Factors: [Key factors influencing risk and therapy selection]

(If provisional, label as such with evidence basis and what is required to finalize.)

Assessment

[Summary of diagnosis, disease extent, and major therapy constraints]

• Confirmed Diagnoses: [List]
• Working Diagnoses: [List with differential if uncertain]
• Active Complications: [List with status]
• Treatment-Limiting Comorbidities: [List]

Plan

Primary Cancer

• Treatment Intent: [curative / disease control / palliative]
• Options and Recommendation: [Options discussed, recommended plan with sequencing, rationale based on stage/biomarkers/PS/comorbidities]
• Regimen Details: [Regimen name, route, cycle length, monitoring, key toxicities] (If initiating.)
• Prerequisites: [What must occur before treatment starts] (If not initiating today.)
• Shared Decision-Making: [Patient goals/values; benefits/risks/alternatives discussed; patient questions; stated preference]

Staging and Diagnostic Completion

• [Additional workup needed; urgency; expected turnaround]

Symptom Management

• [Pain management; bowel regimen if on opioids; antiemetics; other symptom interventions]
• [Supportive referrals: palliative care, nutrition, PT/OT, psycho-oncology] (As indicated.)

Supportive Care and Safety

• [VTE risk and anticoagulation plan]
• [Infection prophylaxis and vaccinations]
• [Bone health agents if applicable]
• [Drug interaction review and adjustments]

Hereditary Risk

• [Germline testing indication; genetics referral status; implications discussed]

Fertility Preservation

• [Fertility risk discussion; preservation referral; pregnancy testing; contraception] (Include when patient has reproductive potential and therapy may affect fertility.)

Care Coordination

• [Communication with referring clinician]
• [Multidisciplinary coordination: tumor board, surgery, radiation oncology]
• [Follow-up timing and what must be available by next visit]

Patient Education and Consent

• Education Provided: [Topics covered]
• Consent Status: [obtained and documented / to be obtained before treatment initiation]
• Safety Net: [Contact for concerns, after-hours number, red-flag symptoms requiring urgent evaluation]

Time and Medical Decision-Making

[Total time on date of service] or [MDM complexity: problems addressed, data reviewed including external records, management risk] (Document independent interpretation of imaging/tests and interprofessional communication when performed.)