On Beam Note Template

OVERALL_INSTRUCTIONS

Chief Complaint

On Beam Note

Template

[Patient Name] Oncology # [Oncology Number] Date: [Date of Note] Date of Birth: [Patient Date of Birth] Referring Physician: Dr. [name] DIAGNOSIS: [[Provide a detailed diagnosis including the tumor classification (e.g., T, N, M stages), type of carcinoma, specific location, and overall stage. Use a concise narrative paragraph style to summarize the diagnosis.] For example: [T3 N2b M0 SQUAMOUS CELL CARCINOMA OF THE RIGHT BASE OF TONGUE, STAGE IVA.]] RADIATION DOSE: [[Specify the radiation dose, number of fractions, and the targeted area.] For example: [Number of fractions], [Total Dose] Gy to the [Targeted Area].] PROGRESS REPORT: [[Summarize the patient's progress since the last visit. Include details about symptoms, pain levels, appetite, and any other relevant observations.] For example: [Patient Name] returns today for routine on-treatment visit. [He/She/They] reports [symptoms and severity]. Appetite remains [good/poor]. [He/She/They] denies [specific symptoms].] PHYSICAL EXAM: Vital signs: Height [height] inches, weight [weight] pounds, temperature [temperature], pulse [pulse], respirations [respirations], blood pressure [blood_pressure], O2 saturation [oxygen saturation].. (Write the following examination as it is, If certain systems have findings, replace that section with [Detailed System findings] instead) General: Well-nourished, well-developed [ethnicity] male in no acute distress. HEENT: Normocephalic. Eyes EOMI, PERRLA. Sclerae are anicteric. Oral cavity is clear. No thrush or mucositis. Neck: No adenopathy. No supraclavicular or axillary adenopathy present. Lungs: Clear to auscultation bilaterally. There are no rales, rhonchi, or wheezing. Cardiac: Regular rate and rhythm with no rubs, murmurs, or gallops. Abdomen: Benign, soft, nontender. Positive bowel sounds. No masses or organomegaly. No inguinal adenopathy. Extremities: No peripheral edema or adenopathy. Neuro: Non-focal. Alert and oriented x [number]. Gait is normal. Musculoskeletal: No point tenderness to percussion or palpation of the spine. Skin: Intact. No breakdown. Psych: Mood and affect are appropriate. Remainder of examination is noncontributory. ] LABORATORY STUDIES: [Provide details of relevant laboratory studies, including dates and results. The result will include and not limited to WBC [number], hemoglobin [number], hematocrit [number], platelets [number], sodium [number], potassium [number], chloride [number], glucose [number], calcium [number], BUN [number], creatinine [number], albumin [number], total bilirubin [number], alk phos [number], ALT [number], AST [number].] For example: [Date 1]: [Lab Test and Results] [Date 2]: [Lab Test and Results] [Date 3]: [Lab Test and Results] RADIOGRAPHIC STUDIES: [Describe the radiographic studies performed, including the purpose and findings. For example: [Imaging Modality] scans [frequency] for the purposes of [Purpose].] ASSESSMENT/PLAN: [[Provide an assessment of the patient's condition and the plan for ongoing treatment. Include details about the response to treatment, any changes in therapy, and medications.] For example: [Patient Name] will continue therapy as planned. [He/She/They] is having a [favorable/poor] response to treatment. Radiographically, there is [description of findings]. Clinically, [he/she/they] notes [improvements or concerns]. [He/She/They] will continue [specific treatments] as planned. [He/She/They] will continue [current medications]. No new prescriptions were given today.]