Radiation Therapy Toxicity Check Note (Unscheduled Visit)

Visit Details

Date/Time: [date and time]
Patient: [patient name/identifier]
Provider: [role and attending/supervisor if applicable]
Visit Type: Unscheduled RT toxicity evaluation
Modality: [in-person / telehealth / phone] (If remote, note exam limitations and specify what is patient-reported vs clinician-observed.)

Chief Concern & RT Course Context

Reason for Visit: [primary toxicity trigger, onset, and urgency context; optional brief patient quote]

Active RT Course: [treated site/region] — [treatment intent] — [current fraction # and dose-to-date] — [planned total dose/fractions] — [concurrent systemic therapy if applicable] — [treatment interruptions to date if any]

Focused History

[Narrative of chief toxicity concern with timeline, severity, and functional impact supporting grading (diet limitations, ADL interference, hydration status, hospitalization risk). Include site-specific symptom probes relevant to treated region (skin changes; oral intake/dysphagia; GI frequency/consistency/bleeding; GU urgency/dysuria/hematuria/retention). Document interventions already attempted and response. Screen for relevant red flags (fever, inability to tolerate PO, syncope, uncontrolled pain, bleeding, retention, confusion). Include pertinent baseline symptoms or comorbidities only if directly relevant to the differential.] (Keep concise and problem-focused.)

Objective

• Vitals/Status: [relevant vitals] [weight and trend if pertinent] [performance status if affecting decisions] [pain score and regimen effectiveness]
• Exam: [targeted findings relevant to grading and ruling out emergencies] (Skin: location, erythema vs dry vs moist desquamation, infection signs. Oral/pharynx: mucosal changes, hydration, swallow. GI/GU: tenderness, distention, perineal skin if in field. General appearance and mental status if dehydration/sepsis concern. If telehealth, specify observed vs patient-reported.)
• Data: [pertinent labs/cultures/imaging reviewed today] (Only include data used for decision-making.)

Toxicity Grading & Assessment

Grading System: [CTCAE vX.X / RTOG acute criteria — specify version]

[Toxicity label, e.g., radiation dermatitis, oral mucositis, esophagitis, enteritis/proctitis, cystitis]

• Grade: [0–5]
• Supporting Criteria: [symptom severity, functional impact, objective findings, and intervention requirements that justify the grade]
• Attribution: [RT / concurrent therapy / other] — [unrelated / possible / probable / definite]
• Trajectory: [worsening / stable / improving]

(Repeat toxicity block above for each toxicity addressed. If grading cannot be supported, document: "Grade unable to determine—insufficient objective criteria documented today.")

Assessment: [Problem-oriented summary in descending severity. State whether findings are consistent with RT effect; note key differentials when safety-relevant (infectious vs RT etiology). Include contributing factors and complication risk when clinically relevant.]

Plan

• Interventions: [medications prescribed/adjusted with dose/route/frequency; non-pharmacologic care (dressings, rinses, diet); procedures performed; IV fluids]
• RT Course Decision: [continue as planned / treat-and-continue / hold with criteria to resume / urgent evaluation needed] (If holding, document dates and who will reassess.)
• Coordination: [consults/referrals placed; communication with other treating teams]
• Follow-up: [next contact date/timeframe; next OTV or physician visit; labs or reassessments before next fraction]
• Return Precautions: [explicit symptoms requiring urgent call or ED visit, tailored to toxicity type] (Document that precautions were reviewed with patient/caregiver.)