Pediatric Oncology SOAP Note

Date/Time of Service: [date and time]

Patient: [name and identifier]

Primary Diagnosis/Service Line: [primary oncologic diagnosis / service line]

Protocol/Regimen: [protocol name or regimen], [cycle/day], [curative / disease control / palliation] (If unknown at time of documentation, enter [pending] and update when confirmed.)

Historian(s): [patient / parent-guardian / both]; interpreter: [yes / no / not needed]

Allergies/Adverse Reactions: [list reactions or NKDA] (If not obtainable, enter Unknown/unavailable—[reason].)

Subjective

Chief Concern: [one-line visit purpose or patient/family framing]

Interval History: [oncologic context and interval events] (Open with diagnosis, treatment phase, time since last therapy, and key interim events such as ED visits, admissions, transfusions, or dose modifications. Then summarize interval symptoms and treatment tolerance with a toxicity-first lens: fever/infection, GI symptoms, mucositis, pain, neurologic changes, bleeding/bruising, fatigue, medication adherence. For infusion pre-assessment, state whether prior toxicities have resolved to baseline and list any new medications or supplements. For inpatient rounding, include overnight events, fever curve, pain control, intake/output, and family concerns. Quantify significant toxicities with grade and functional impact when they influence treatment decisions.)

Functional Status: [Lansky / Karnofsky / ECOG score]; [improved / stable / declined from baseline] (Include only if assessed today or if changes affect decisions; omit section if unchanged and not decision-driving.)

Psychosocial: [caregiver availability, school impact, transportation or medication access barriers, distress or support needs] (Include briefly if relevant today; omit section if not addressed.)

Objective

Vitals/Growth: [date/time; BP, HR, Temp, RR, SpO2; weight in kg with date; height/BSA if dosing-relevant; pain score; I/O summary for inpatients if clinically important] (If therapy is planned, weight/BSA are hard-stop fields—use [pending] if not yet available.)

Exam: [focused, problem-relevant findings] (Document what supports today's assessment rather than exhaustive normals. Include general appearance/hydration, oral cavity for mucositis, cardiopulmonary status, abdomen, skin/petechiae, neuro, and central access device site and patency if therapy is planned.)

Data: [dated labs, imaging, procedures, transfusions driving decisions] (Include CBC with ANC, regimen-relevant chemistries, microbiology if infection concern, tumor markers or disease-specific labs as applicable. For imaging, note study type, date, and key impression with response or progression status. For recent procedures or transfusions, include date and pertinent details. Conclude with a brief interpretation linking data to the plan.)

Pending: [items outstanding and planned action upon result] (Include only if results are pending; omit section otherwise.)

Assessment

Summary: [diagnosis; treatment phase with protocol/regimen and cycle/day; overall clinical status today; key drivers of decisions such as toxicity grade, ANC threshold status, or response assessment findings] (Write as 2–3 concise sentences.)

Active Problems:

1. [Problem 1: disease/treatment delivery or most urgent issue]
2. [Problem 2: toxicity, infection, or supportive care issue]
3. [Problem 3: additional active problem] (Add or remove numbered problems as needed to match today's encounter.)

Plan

1. [Problem 1]: [brief status statement with supporting evidence]

   • Diagnostics: [tests/orders with timing and purpose]
   • Therapeutics: [medications with dose/route/frequency; non-pharmacologic treatments; procedures]
   • Monitoring: [vitals/labs/assessments and frequency; toxicity surveillance]
   • Contingencies: [thresholds for escalation, dose holds, or additional workup]

   (For the primary oncology problem, include: regimen context with dose level; treatment planned today with agents/routes or reference to signed orders; eligibility check with specific values—counts, renal/hepatic function, performance status, toxicity recovery; dose modifications with rationale if any; and required protocol surveillance.)

2. [Problem 2]: [brief status statement with toxicity grade and functional impact if applicable]

   • Diagnostics: [targeted tests to evaluate severity or cause]
   • Therapeutics: [interventions tied to toxicity grade with measurable goal]
   • Monitoring: [parameters and frequency to track resolution]
   • Contingencies: [criteria for dose adjustment, hospitalization, or consult]

   (For infection, specify neutropenic vs non-neutropenic status, central line presence, culture sources/timing, empiric therapy with de-escalation plan, and prophylaxis. For transfusion, document thresholds and product requirements including irradiation/CMV status.)

3. [Problem 3]: [brief status statement]

   • Diagnostics: [if applicable]
   • Therapeutics: [if applicable]
   • Monitoring: [if applicable]
   • Contingencies: [if applicable]

   (Add or remove numbered problems to match the Assessment problem list.)

Disposition/Follow-up: [next steps by setting] (For clinic: next visit timing, required pre-cycle labs, return precautions with explicit thresholds—fever ≥38°C, uncontrolled vomiting, bleeding, lethargy. For infusion: proceed/hold decision, monitoring plan, post-infusion instructions. For inpatient: discharge criteria, expected date, outpatient follow-up.)

Communication: [individuals/teams with whom plan was discussed; consent/assent status if new regimen; consults requested]