Survivorship Clinic Note (COG LTFU-Based)

Encounter Information

Patient: [Full name] | MRN: [MRN] | DOB: [DOB] | Age: [Age] | Sex: [Sex]

Encounter Date: [Date] | Clinic Location: [Clinic/Institution] | Clinician: [Name, credentials, role]

Guideline Basis: [COG LTFU Guidelines vX.X] | Guideline logic executed: [Date]

Treatment Records: [complete / partial / pending] — [Brief note of missing elements if applicable] (If partial/pending, screening recommendations may be unreliable; create retrieval tasks below.)

Reason for Visit

[Patient-stated goals or concerns for survivorship visit] (Use direct quote if impactful; include guardian goals if patient is a minor.)

• Interval medical events: [New diagnoses, hospitalizations, or medication changes since last visit] (Omit if none.)
• Potential late-effect symptoms: [Relevant new symptoms such as fatigue, dyspnea, neuropathy, hearing changes, menstrual changes] (Omit if none reported.)
• Functional/psychosocial: [School/work performance, distress, insurance/access barriers] (Brief; omit if unchanged.)

Treatment Exposure Summary

Diagnosis

• Primary diagnosis: [Diagnosis, histology] | Date of diagnosis: [Date] | Age at diagnosis: [Age]
• Stage/Risk group: [Stage/Risk group] (If applicable.)
• Relapse history: [None / Dates and sites] (If applicable.)
• Date therapy completed: [Date]
• Cancer predisposition testing: [performed / declined / pending / unknown] — [Result or plan if applicable]

Exposures

(List known exposures; label unknowns as pending/estimated. Do not silently omit.)

• Chemotherapy/Systemic therapy: [Agent, route, cumulative dose for each; emphasize anthracyclines, alkylators, platinum, bleomycin; include targeted/biologic/immunotherapies]
• Radiation therapy: [Field/site, laterality, total dose in Gy, fractionation, modality, dates for each field]
• Surgery: [Procedure, site/laterality, significant complications]
• HCT/Cellular therapy: [Type (auto/allo/CAR-T), conditioning regimen, infusion date, stem cell source, chronic GVHD status] (Omit if not applicable.)
• Other modalities: [Radioiodine, MIBG, other] (Omit if not applicable.)

Established Late Effects

• [Late effect]: [Date diagnosed] — [Current status] — [Managing provider]
• (Repeat for each established late effect; include relevant acute complications informing risk.)

Data Gaps

• [Missing item] — [Action to retrieve, target date, responsible person]

Objective

Vitals: [BP, HR, weight, BMI, other relevant measurements] (Include percentiles for pediatrics.)

Exam: [Targeted exam tied to exposure risks; pertinent positives and negatives]

Data Reviewed:

• [Study type]: [Date] — [Key result] — [Interpretation]
• (Repeat for relevant prior studies: echo, PFTs, audiology, endocrine labs, DXA, imaging.)

Risk Assessment & Surveillance Schedule

(Organize by organ system. For each relevant system, document triggering exposure(s), risk, current status, recommended screening with interval, next due date, and ownership. Omit systems without relevant exposures if asymptomatic.)

Cardiac

• Exposure(s): [Anthracycline dose, chest RT, other cardiotoxic agents]
• Risk: [Cardiomyopathy / heart failure / arrhythmia / coronary disease]
• Status: [asymptomatic / symptomatic / diagnosed / treated]
• Screening: [Test, interval] | Next due: [Date] | Owner: [Survivorship / PCP / Cardiology]

Pulmonary

• Exposure(s): [Bleomycin, thoracic RT, busulfan, HCT]
• Risk: [Pulmonary fibrosis / restrictive / obstructive disease]
• Status: [asymptomatic / symptomatic / diagnosed / treated]
• Screening: [Test, interval] | Next due: [Date] | Owner: [Survivorship / PCP / Pulmonology]

Endocrine/Metabolic

• Exposure(s): [Cranial/neck RT, TBI, alkylators, steroids, HCT]
• Risk: [Hypothyroidism / growth issues / metabolic syndrome / gonadal dysfunction]
• Status: [asymptomatic / symptomatic / diagnosed / treated]
• Screening: [Test, interval] | Next due: [Date] | Owner: [Survivorship / PCP / Endocrinology]

Neurocognitive

• Exposure(s): [CNS disease/RT, high-dose MTX/cytarabine, HCT]
• Risk: [Cognitive / learning / attention / executive function issues]
• Status: [asymptomatic / symptomatic / diagnosed / treated]
• Screening: [Test, interval] | Next due: [Date] | Owner: [Survivorship / PCP / Neuropsychology]

Auditory/Vision

• Exposure(s): [Cisplatin/carboplatin, cranial RT, steroids]
• Risk: [Sensorineural hearing loss / cataracts / vision changes]
• Status: [asymptomatic / symptomatic / diagnosed / treated]
• Screening: [Test, interval] | Next due: [Date] | Owner: [Survivorship / PCP / Audiology / Ophthalmology]

Musculoskeletal/Bone Health

• Exposure(s): [Steroids, MTX, RT to bone, HCT]
• Risk: [Osteopenia / osteoporosis / AVN / muscle weakness]
• Status: [asymptomatic / symptomatic / diagnosed / treated]
• Screening: [Test, interval] | Next due: [Date] | Owner: [Survivorship / PCP / Endocrinology]

Renal

• Exposure(s): [Ifosfamide, cisplatin, renal RT/surgery]
• Risk: [CKD / tubular dysfunction / hypertension]
• Status: [asymptomatic / symptomatic / diagnosed / treated]
• Screening: [Test, interval] | Next due: [Date] | Owner: [Survivorship / PCP / Nephrology]

GI/Hepatic

• Exposure(s): [Hepatotoxic chemotherapy, abdominal RT, HCT]
• Risk: [Liver dysfunction / strictures / chronic GI symptoms]
• Status: [asymptomatic / symptomatic / diagnosed / treated]
• Screening: [Test, interval] | Next due: [Date] | Owner: [Survivorship / PCP / GI]

Reproductive/Fertility

• Exposure(s): [Alkylators, pelvic/cranial RT, TBI, gonadal surgery]
• Risk: [Infertility / hypogonadism / pregnancy complications]
• Status: [asymptomatic / symptomatic / diagnosed / treated]
• Screening: [Test, interval] | Next due: [Date] | Owner: [Survivorship / PCP / Reproductive specialist]

Subsequent Neoplasms

• Exposure(s): [RT fields, alkylators, topoisomerase II inhibitors, genetic predisposition]
• Risk: [Site-specific second malignancy risk]
• Status: [asymptomatic / symptomatic / diagnosed / treated]
• Screening: [Test, interval per exposure and age] | Next due: [Date] | Owner: [Survivorship / PCP / subspecialty]

Immunizations

• Status: [Up to date / Needs catch-up / Post-HCT revaccination required] — [Gaps or contraindications]
• Live vaccines: [Contraindicated / Allowed] (Post-HCT requires transplant team clearance.)

Due Now/Overdue & Orders Placed

• [Test/screening] — [Ordered / scheduled / referred] — [Owner]

Assessment & Plan

(Organize by problem or late-effect domain. For each, link exposure to current status and specify plan, ownership, and follow-up. Document and justify any deviations from guideline-based screening.)

[Problem #1]

Assessment: [Exposure basis, current findings/status, risk level]

• Plan: [Screening/monitoring with interval; interventions; referrals with clinical question]
• Owner: [Survivorship / PCP / Subspecialist] | Follow-up: [Interval]
• Guideline deviation: [If applicable, document rationale]

(Repeat for additional problems as needed.)

Education & Counseling

• Topics: [Late effects, screening rationale, health behaviors, fertility, psychosocial resources]
• Materials: [Handouts, survivorship care plan provided]
• Understanding: [Patient/family comprehension; any deferrals with risks discussed]

Care Coordination

• Referrals: [Service — clinical question — status]
• Records requested: [Source — items — responsible person]
• PCP communication: [Summary sent via portal/fax, date]
• Survivorship care plan: [Generated/updated — delivered to patient portal/PCP]

Follow-up & Safety

• Next survivorship visit: [Interval or date]
• Return precautions: [New cardiopulmonary symptoms, neurologic changes, abnormal bleeding, fever, other exposure-relevant red flags]
• Contact: [Clinic phone, after-hours instructions, patient portal]