Radiation Therapy Follow-Up Visit Note

Date: [Date of visit]

Patient: [Patient name and identifiers]

Provider: [Clinician name and credentials]

Visit Type: [routine surveillance / symptom-driven]

Time Since RT Completion: [Time interval]

Oncologic Summary

Diagnosis: [Primary site; histology; stage; key biomarkers; treatment intent]. RT Course: [Treated site(s); modality/technique; dose per fraction; total dose; number of fractions; start and end dates; treatment breaks if any]. Other Treatments: [Relevant surgery with date(s); systemic therapy with agents and dates; current cancer-directed therapy status]. (If RT details are unavailable, explicitly state that outside records have been requested. Do not estimate values.)

Interval History

[Brief narrative identifying patient context, time since RT completion, last visit date, and purpose of today's visit. Include interval developments: new or worsening symptoms, hospitalizations, procedures, and systemic therapy changes.]

Late Toxicity Assessment: [For each clinically relevant toxicity: toxicity term, CTCAE grade, attribution (RT-related / multifactorial / unrelated), time course, and current management] (If late toxicity assessment was not performed, explicitly state the reason. Do not auto-fill "none.")

Performance Status: [ECOG 0–5 / Karnofsky 0–100%]; [relevant changes in functional status, pain, or symptom burden]

Objective

Vitals: [Relevant measurements; weight with trend]

Exam: [Pertinent findings by system, emphasizing irradiated region and treatment-related changes such as fibrosis, skin changes, lymphedema, or mucosal changes] (For telehealth visits, note exam limitations.)

Data Reviewed: [Imaging studies with dates, comparisons, and key findings relevant to disease status; labs and tumor markers with trends; pathology or procedure results as applicable] (Summarize succinctly; include interpreting impression when available.)

Assessment

Disease Status: [no evidence of disease / stable disease / partial response / complete response / progressive disease / indeterminate] (State the basis for this determination, citing specific imaging dates or exam findings.)

Late Effects: [Summary of clinically significant toxicities; distinguish active issues requiring intervention from stable chronic sequelae]

[Other clinically relevant problems affecting surveillance or management] (Include only if applicable.)

Plan

• Surveillance: [Next imaging and labs with timing; ordering clinician; plan for results communication]
• Late Effects Management: [Medications, supportive therapies, or referrals for active toxicities]
• Survivorship Counseling: [Counseling provided; coordination with PCP for preventive health]
• Care Coordination: [Communications to other services; which team is responsible for ongoing surveillance]
• Return Precautions: [Symptoms that should prompt earlier evaluation]
• Follow-Up: [Timing; visit format; with which clinician]

(Document only information explicitly available from the encounter. If data are pending, state this clearly.)