Pediatric Oncology Initial Consultation Note

Encounter Information

Date/Time: [Date and time]
Location: [Clinic/facility and room or department]
Service: Pediatric Hematology/Oncology
Consulting Clinician: [Name, credentials, role]
Visit Type: [new consult / second opinion / transfer of care]
Referral Source: [self / PCP / specialist / hospital discharge] — Referring Clinician: [Name, specialty, organization]
Reason for Consult: [Primary reason and explicit consult questions]
Participants Present: [Patient name and age] | [Parent/guardian names and relationships] | [Other participants if present]
Interpreter: [Yes — language and modality / No / Not applicable]
Historian Reliability: [Adequate / Limited — brief explanation if limited]

Chief Concern

[Primary concern] (Include a brief patient or family quote if it clarifies the concern.)

Outside Records and Data Reviewed

Reviewed:

• [Oncology notes — source, date]
• [Pathology reports — specimen type, date, report only vs institutional review completed]
• [Imaging studies — modality, region, date, images personally reviewed vs report only]
• [Laboratory data — test names, dates]
• [Molecular/cytogenetic reports — assay type, lab, date]

Pending/Requested:

• [Records requested — facility, date of request]
• [Imaging CD pending — modality and dates]
• [Pathology slides/blocks requested for institutional review — status]
• [Molecular testing — ordered vs pending results]

History of Present Illness

[Narrative summary including: presenting symptoms and onset; diagnostic journey with who identified abnormalities, where, and when; current symptom burden and functional status; prior interventions and response; family understanding and goals for this consultation. Include pediatric oncology elements as relevant: constitutional symptoms, pain pattern, neurologic symptoms, bleeding/bruising, infection history, weight/appetite changes, urgent complications such as tumor lysis, cord compression, febrile neutropenia, or hemorrhage.] (Use source attribution throughout, e.g., Per parent report, Per outside ED note dated. Keep as a concise, coherent paragraph.)

Key Oncology Timeline:

• [Date] — [First symptoms]
• [Date] — [First abnormal test and result]
• [Date] — [Biopsy or diagnostic procedure]
• [Date] — [Diagnosis provided — clinician/institution]
• [Date] — [Staging studies completed]
• [Date] — [Therapy initiated]
• [Date] — [Response assessment or relapse event]

Oncology Synopsis

Working Diagnosis: [Confirmed / Suspected] — [Diagnosis] (By [institution/clinician])
Primary Site/Histology or Leukemia/Lymphoma Subtype: [Value / Pending / Unknown]
Disease Status: [New diagnosis / Relapse] | [Localized / Metastatic] | [Responding / Stable / Refractory / Unknown]
Staging System: [System name] — Assigned Stage: [Stage / Pending — explanation]
Risk Group: [Risk category and key defining features / Pending]
Prior Therapy Summary: [Surgery / Chemotherapy / Radiation / Transplant / Immunotherapy — brief summary / None]
Current Therapy Status: [Untreated / On therapy / Completed therapy] — [Last treatment date] — [Current complications]
Institutional Pathology Review: [Complete / Pending / Not yet requested]
Data Gaps: [Unknown items and retrieval plan]

Past History

• Medical History: [Chronic conditions affecting therapy risk; prior serious infections; immunodeficiency; anesthetic complications]
• Surgical/Procedural History: [Biopsies; central lines; major surgeries; prior radiation fields]
• Birth/Developmental: [Gestational age; NICU course; milestones; neurodevelopmental diagnoses] (Include if relevant to current presentation or therapy planning.)
• Immunizations: [Up to date / Delayed — notable gaps or contraindications]
• Transfusion History: [Prior transfusions; reactions; special requirements such as CMV-negative or irradiated]

Medications

• Active Medications: [Name, dose, route, frequency, indication]
• Recent or Intermittent: [Steroids, antimicrobials, antiemetics, pain medications]
• Historical Medications: [Prior medications if relevant] (For second opinions, distinguish active from historical medications.)

Allergies and Hypersensitivity

• [Allergen] — [Reaction type and severity]
• [Chemotherapy/immunotherapy hypersensitivity if applicable] — [Agent, reaction, management, rechallenge outcome]

(Document No known drug allergies or Unable to obtain allergy history if applicable.)

Family History

• Oncologic/Hematologic History: [Early-onset cancers, multiple primaries, hematologic malignancies, unexplained cytopenias, marrow failure syndromes, consanguinity]
• Known Familial Syndromes: [Present — details / Absent / Unknown]
• Genetic Counseling/Testing: [Performed — test type, lab, date, key results, limitations / Not performed — criteria met? referral recommended?]

Social History and Psychosocial Assessment

[Brief narrative: household composition, primary caregivers, custody/guardianship status, school grade and supports, distance from treating center.]

• Psychosocial: [Family coping, distress level, safety concerns, existing mental health supports, child life needs]
• Social Determinants/Barriers: [Transportation, housing, food security, caregiver employment, insurance, language access]
• Referrals Made: [Social work, financial counseling, lodging]
• Adolescent Confidential Interview: [Completed — topics covered / Not performed — reason] (Include for patients age 12 and older.)

Review of Systems

(Problem-focused; include systems discussed. Note if full ROS not obtained due to acuity.)

• Constitutional: [Fevers, night sweats, weight change, fatigue]
• Hematologic/Bleeding: [Bruising, bleeding, pallor]
• Infection: [Recurrent or severe infections]
• Neurologic: [Headache, focal deficits, seizures]
• Respiratory: [Cough, dyspnea]
• GI: [Nausea, vomiting, diarrhea, constipation, abdominal pain]
• GU: [Hematuria, dysuria]
• Musculoskeletal: [Bone or joint pain, limp]
• Skin: [Rash, lesions]
• Psychological: [Mood, sleep, anxiety]

Vitals and Growth

Weight: [Value and percentile]
Height: [Value and percentile]
BMI Percentile: [Value]
Temperature: [Value and route]
Blood Pressure: [Value and pediatric percentile if available]
Heart Rate: [Value]
Respiratory Rate: [Value]
SpO2: [Value — room air / supplemental O2]

Performance Status

[Lansky (age <16) / Karnofsky (age ≥16)]: [Score]% — [Brief functional narrative]

Physical Examination

(Note examination limitations if present.)

• General: [Appearance, distress, toxicity]
• HEENT/Mucositis: [Findings]
• Lymph Nodes: [Cervical, axillary, inguinal, supraclavicular — size, tenderness, mobility]
• Cardiovascular: [Findings]
• Respiratory: [Findings]
• Abdomen: [Hepatosplenomegaly, masses, tenderness]
• Extremities/Musculoskeletal: [Swelling, tenderness, range of motion]
• Skin: [Bruising, petechiae, rashes, lesions]
• Neurologic: [Mental status, cranial nerves, strength, sensation, reflexes]
• Gait: [Assessment]
• Genitourinary: [Testicular exam findings] (Include when indicated and appropriate.)
• Central Line: [Site, type, condition, signs of infection] (If present.)

Data Reviewed

Laboratory Data

• [Key abnormalities and trends — dates — external vs in-house]
• [Tumor markers or disease-specific labs — values and dates]

Imaging

• [Date] — [Modality and region] — [Key findings] — [Images personally reviewed / Report only]

(Note discrepancies between reports or between report and personal review.)

Pathology

Specimen Type and Site: [Value / Cannot be determined]
Diagnosis: [Histology/subtype / Pending / Cannot be determined]
Immunophenotype/Flow Results: [Value / Pending / Not performed]
Cytogenetics/Molecular Findings: [Key abnormalities / Pending / Not performed]
Margins/Nodal Status: [Value / Not applicable]
Tumor Grade: [Value / Not applicable]
Review Status: [Outside report only / Institutional review complete / Institutional review pending]

Assessment

[Summary paragraph: This is a [age]-year-old [sex] with [suspected/confirmed diagnosis] presenting for [new consult / second opinion / transfer of care]. Key findings include [brief list]. Currently [clinically stable / unstable]. Stage and risk are [known / pending]. Immediate priorities are [list].]

Diagnostic Certainty: [Confirmed with institutional confirmation / Presumptive / Differential open — list top considerations and data needed to resolve]

Prioritized Problem List:

• [Primary malignancy and current status]
• [Acute issues: pain, infection risk, cytopenias, mass effect, metabolic derangements]
• [Treatment readiness: organ function, venous access, logistical barriers]
• [Psychosocial concerns impacting care]
• [Genetic predisposition question] (If active.)

Plan

Primary Malignancy

• Diagnosis Confirmation: [Pathology review steps, additional testing, repeat biopsy if needed, urgency]
• Staging and Risk Stratification: [Staging system; required studies ordered/pending; known vs pending risk features]
• Disease Status: [New vs relapse; measurable disease sites; baseline burden]
• Treatment Strategy: [Intent — curative vs disease control vs palliation; options presented; clinical trial discussion] (For second opinions, distinguish recommendations from orders and clarify whether assuming ongoing care.)
• Regimen Plan: [Protocol/regimen name; drug classes; route; cycle structure; required pre-therapy evaluations; monitoring cadence] (Include if initiating therapy. Avoid finalizing doses if not yet determined.)
• Surgery/Radiation Coordination: [Consults, indications, timing, treating teams] (If applicable.)

Supportive Care

• Pain: [Severity, current regimen, escalation plan]
• Infection Precautions: [Prophylaxis, fever plan, 24/7 contact instructions]
• Cytopenias/Bleeding: [Transfusion thresholds and product specifications; activity restrictions]
• Nausea/Nutrition: [Antiemetic strategy; dietitian referral; appetite support]
• Fertility Preservation: [Risk counseling documented; referral; time-sensitivity]
• Central Line: [Type, timing, care instructions] (If indicated.)
• Immunizations: [Reconciliation; timing around therapy; household guidance]

Psychosocial and School Support

• [Screening findings; coping; identified supports]
• [Referrals: social work, psychology, child life, spiritual care]
• [School liaison; 504/IEP planning; home-hospital instruction] (If applicable.)

Counseling and Education

• Counseled: [Who was counseled; interpreter use]
• Diagnosis Discussion: [Diagnosis explanation and uncertainties addressed]
• Staging/Risk Discussion: [Staging and risk explained in plain language]
• Treatment Discussion: [Options, risks, benefits, alternatives discussed]
• Toxicity Overview: [Anticipated toxicities reviewed]
• Family Goals: [Family goals and stated preferences]
• Understanding Confirmed: [Family verbalized understanding of key points]
• Materials Provided: [Written materials, emergency contact information, return precautions]

Consent and Assent Status

Legal Guardian: [Name and authority]
Consent: [Obtained today / Planned — timing / Deferred — reason]
Assent: [Obtained / Developmentally appropriate approach used / Not applicable — reason]

Follow-Up and Care Coordination

• Orders Placed: [Tests, imaging, procedures — timing]
• Referrals: [Specialists and services — timing]
• Tumor Board: [Planned date / Request submitted / Not indicated]
• Next Appointment: [Date, modality, purpose]
• Communication: [Summary to referring clinician and PCP — method and timing] (For second opinions, include written summary and next steps for family and referring team.)