Radiation Therapy On-Treatment Visit Note

Date/Time: [Date and time of encounter]

Author: [Author name, role/credentials] (If trainee-authored, include supervising attending: [Supervising attending name, role])

Course Identifier: [RT course name/number; plan/phase if applicable]

RT Course & Treatment Status

[Diagnosis and stage if relevant] — [curative / adjuvant / palliative] intent. [Treated site(s) with laterality]. Concurrent systemic therapy: [agent/regimen / none].

• Prescription: [Dose per fraction] × [Planned number of fractions] = [Planned total dose].
• Delivery status: Fraction [Current fraction] of [Planned fractions]; Cumulative dose: [Dose to date]; Start: [Start date]; Anticipated end: [End date].
• Interruptions/deviations: [None / Description with dates and reasons].
• Management activities reviewed: [Verification imaging / setup parameters / delivery parameters reviewed today].

Interval History

[1–2 sentence synopsis of overall status since last visit]

• Treatment-site symptoms: [Symptoms, changes since last visit, onset, severity, impact].
• Pain: [Location; severity; response to analgesics].
• Nutrition/oral intake: [Appetite, PO intake, weight trend, hydration].
• Functional status: [Current function and trend].
• Intercurrent events: [ED visits / hospitalizations / infections / medication changes with dates] (Omit if none.)
• Adherence: [Missed fractions or medication adherence issues with reasons] (Omit if no issues.)

Objective

• Vitals: BP [BP]; HR [HR]; Temp [Temp]; SpO2 [SpO2]; Weight [Weight]; Pain [0–10].
• Focused exam: [Findings relevant to treated site and active toxicities]. (If limited, state reason.)
• Pertinent data: [Labs/imaging affecting this week's management with dates] (Omit if none.)

Toxicity Assessment

Grading scale: [CTCAE v5.0 / CTCAE v6.0 / institutional scale]

• [Toxicity name]: Grade [0–5] — [Brief descriptor justifying grade]. Attribution: [RT / systemic therapy / other]. Trend: [improved / stable / worse]. Intervention: [Action taken or none].
• (Repeat for each significant toxicity; if none above Grade 1, state: "No acute toxicities above Grade 1.")

Assessment & Plan

[2–3 sentence synthesis: overall RT tolerance, whether findings reflect expected treatment effects vs concerning findings, any safety concerns]

RT Plan: [Continue RT as planned / Hold RT: reason, anticipated duration, criteria to resume / Modify RT: description and rationale]. Next OTV: [Date or timing].

Supportive Care: [Medication changes (analgesics, antiemetics, topicals, mouth care) / nursing interventions / referrals as applicable]. (Omit categories with no changes.)

Patient Education: [Key counseling points, red flags, when to contact clinic or ED].

(If critical information is missing to determine continue/hold/modify, document what is missing and interim safety plan.)