Radiation Oncology Consultation Note

Patient Name: [Full name]

MRN: [MRN]

Date of Birth: [DOB]

Age: [Age]

Sex: [Sex]

Date of Encounter: [Date]

Referring Clinician: [Name, specialty/service, institution]

Reason for Consult: [One-line problem statement for RT evaluation]

Chief Complaint

"Referred by [clinician/service] for consideration of radiation therapy for [diagnosis/region/symptom]." [Urgency features if present: cord compression / bleeding / neurologic compromise / airway compromise / other]

History of Present Illness

[Oncologic timeline and current symptom assessment: date and manner of diagnosis; symptom evolution with onset, severity, and pattern; diagnostic milestones with dates; current symptoms with severity scores where relevant; functional status and weight changes; patient understanding of condition and articulated goals] (Use chronological narrative format. Include direct patient quotes only if the patient explicitly states goals or values impacting treatment decisions.)

• (Optional timeline for complex histories) [Date: Key event]; [Date: Key event]; [Date: Key event]

Oncologic History

Pathology

• [Date; Specimen/site; Procedure type; Histology; Grade; Biomarkers/molecular results; Margin status; LVI; PNI; Attribution: personally reviewed / per report]
• [Additional specimens as applicable]

(If pathology is unavailable, document gap and action taken: "Outside pathology requested from [facility] on [date].")

Imaging

• [Modality; Date; Key findings relevant to staging and targeting; Attribution: personally reviewed / per report]
• [Additional studies as applicable]

(If imaging is unavailable, document status and actions taken.)

Staging

Staging system/edition: [e.g., AJCC 8th edition]

Stage: [cT/cN/cM or pT/pN/pM]; Overall stage group: [Stage]

(If staging is incomplete: "Staging incomplete pending [specific study]; provisional stage based on available data is [stage].")

Performance Status

[ECOG / Karnofsky]: [Score] [Supporting detail if relevant: ambulatory status, ADL support needs, cognitive concerns]

Prior Cancer-Directed Therapies

• Surgery: [Date; Procedure; Site; Margins; Pathologic findings; Complications]
• Systemic therapy: [Regimen; Cycles/dates; Response; Notable toxicities; Current status]
• Prior radiation: [Site(s); Dose/fractions; Dates; Technique; Treating facility; Prior plan availability; Plan requested on date if not available]
• Devices/procedures: [Feeding tube / Tracheostomy / Port / Stent / Other with placement dates and status]

Medical History and Medications

• Relevant comorbidities: [Conditions affecting RT planning or toxicity risk]
• Surgical history: [Surgeries affecting RT planning or positioning]
• Medications: [Current medications; highlight anticoagulants, immunosuppressants, steroids, pain regimen]
• Allergies: [Allergen and reaction type; note contrast allergies]
• Substance use: [Tobacco; Alcohol; Other substances with quantification]
• Social/practical factors: [Living situation; Caregiver support; Transportation; Barriers to daily RT]

(Include only information relevant to RT planning and toxicity risk.)

Review of Systems

• Constitutional: [Fever/chills; Weight change; Fatigue]
• Site-specific baselines: [Baseline function for anticipated treatment field: e.g., urinary/bowel for pelvic RT; swallowing/voice for head and neck RT; neurologic for CNS/spine; respiratory for thoracic RT]
• Other pertinent symptoms: [Symptoms informing staging or RT toxicity baselines]

(Omit extensive ROS that does not inform RT planning.)

Physical Examination

• Vitals: [BP; HR; RR; Temp; SpO2; Weight]
• General: [Appearance; Distress level; Performance status cues]
• Targeted exam: [Primary tumor site findings; Regional nodal basins; Pertinent organ system findings]
• Neurologic: [Mental status; Cranial nerves; Motor/sensory; Gait] (Include for CNS/spine concerns)
• Skin within proposed field: [Integrity; Ulceration; Prior surgical changes; Relevant scars]
• Implanted devices: [Ports; Pacemaker; ICD; Neurostimulator with location]

(For telehealth: "Physical examination limited by video visit" and document observable elements.)

Laboratory Data

• [CBC with date]
• [Chemistry/renal function with date]
• [Tumor markers with date if applicable]

(If labs were not reviewed: "Laboratory data not reviewed at this visit.")

Radiation Safety Screening

Prior Radiation Therapy: [Yes / No / Unknown]. [If yes or unknown: site(s), dose/fractions, dates, treating facility; records status: obtained / requested on date / pending; contingency plan if records pending]

Implanted Electronic Devices: [Pacemaker / ICD / Neurostimulator / Other / None]. [If present: device type, manufacturer/model, location, managing clinic/cardiologist]

Pregnancy Status: [Pregnant / Not pregnant / Unknown / Not applicable]. [If applicable: LMP, pregnancy test result/date, or contraception status]

Positioning Tolerance: [Able to lie flat / Positional pain / Limited ROM / Claustrophobia / Other]. [Immobilization concerns and mitigation plan]

Contrast Safety: [eGFR/Cr with date; Contrast allergy history and premedication plan if needed / Not applicable if no contrast simulation planned]

(Do not infer device presence, pregnancy status, or prior RT exposure. Document explicitly or state "Unknown" with mitigation steps.)

Assessment

Primary Oncologic Problem

[Diagnosis with histology and primary site]; [Stage or staging status]; [Disease status: new diagnosis / recurrence / metastatic]; [Performance status: ECOG or KPS score]; [Key prognostic features].

Treatment intent: [definitive / adjuvant / neoadjuvant / salvage / consolidative / palliative] — [Rationale linked to stage, symptoms, resectability, prior therapy, and evidence base]

Secondary Problems Affecting RT Feasibility

• [Pain control needs]
• [Nutritional compromise / feeding access]
• [Social/transportation barriers]
• [Device considerations and required precautions]
• [Uncertainty regarding prior RT and plan to clarify]
• [Additional problems as applicable]

Discussion and Shared Decision-Making

Treatment intent: [definitive / adjuvant / neoadjuvant / salvage / consolidative / palliative]

Rationale for RT: [Link to stage, symptom burden, resectability, prior therapies, clinical guidelines/evidence]

Alternatives discussed: [Surgery / Systemic therapy / Observation / Supportive care / Hospice / Alternative RT fractionation] [Include why each is or is not preferred]

Risks and benefits counseling: [Acute effects discussed]; [Subacute effects discussed]; [Late effects discussed]. Serious site-specific risks: [Site-specific serious risks tailored to planned field and dose] (Specify risks that were explicitly discussed. Do not use generic "risks and benefits discussed.")

Patient values and preferences: [Patient-stated priorities, goals, tolerance for toxicity tradeoffs]

Understanding and questions: [Questions addressed; confirmation of understanding documented]

Radiation Therapy Recommendation

(Proposed plan pending simulation and treatment planning. Final prescription may adjust based on immobilization, image fusion, and normal tissue constraints.)

• Technique: [3D-CRT / IMRT / VMAT / SBRT / SRS / Electrons / Brachytherapy / Protons]
• Target and scope: [Primary site / Postoperative bed / Involved nodal regions / Elective nodal regions; Laterality]
• Dose and fractionation: [Dose per fraction] × [Number of fractions] = [Total dose] (If not finalized, provide anticipated range and determining factors.)
• Image guidance: [Daily CBCT / kV pair / Surface guidance]; [Motion management: Breath hold / 4DCT / Gating / Abdominal compression / None]
• Critical structures: [Key OARs and planning priorities]
• Concurrent therapy: [Yes / No]. [If yes: agent/regimen, managing clinician, sequencing]
• Simulation instructions: [Position; Arms; Immobilization; Contrast; Scan extent; MRI/PET fusion needs; Prior RT plan fusion; Bowel/bladder prep; Special instructions]

Informed Consent

Consent status: [Obtained today / Deferred]

• (If obtained) [Discussion of nature, purpose, risks (acute/subacute/late, site-specific serious risks), benefits, alternatives, and expected outcomes; questions answered; consent signed for specific RT type; interpreter or legal representative involvement if applicable]
• (If deferred) [Reason: pending staging / patient decision-making / awaiting records / other]; [Plan for when and how consent will be obtained]

Coordination and Next Steps

• Communication: [Summary sent to referring clinician and care team; date/method]
• Tumor board: [Already reviewed on date / Planned for date / Not applicable]
• Care coordination: [Medical oncology / Surgery / Palliative care collaboration and plan]
• Records requested: [Outside pathology / Imaging / Prior RT plans with request date and status]
• Follow-up plan: [CT simulation date / Next clinic visit]; [Triggers for urgent contact]; [For palliative cases: expected timeframe to symptom response]