Radiation Oncology Follow up

OVERALL_INSTRUCTIONS

[Include only relevant positives or negative statements discussed]

Template

INTERVAL HISTORY: CURRENT STATUS: (Instruction: Only include items that were explicitly discussed or mentioned during the encounter.)(Do not include any “No” statements for items that were not discussed.) (If a category has no findings mentioned, omit the category entirely from the note. Include performance status if explicitly reported; otherwise leave blank.) [• Constitutional: [Insert only if discussed, e.g., “Reports fatigue and recent 2 kg weight changes.” "No fever", "chills", "lethargy", "malaise", "fatigue", "loss of appetite".] • ENMT: [Insert only if discussed, e.g., “Reports occasional sore throat.” "No ear pain", "tinnitus", "loss of hearing", "hearing aids", "nosebleeds", "sinusitis", "mouth dryness", "oral bleeding", "mouth ulcers/yeast", "altered taste," "dentures, pain/difficulty swallowing", "sore throat/esophagitis".] • Eyes: [Insert only if discussed, e.g., “No redness/irritation", "loss of vision", "blurred vision", "double vision", "glasses/contacts".] • Endocrine: [Insert only if discussed, e.g., “No diabetes", "thyroid disease", "hot flashes", "night sweats".] • Neck: [Insert only if discussed, e.g., “No pain", "muscle weakness", "decreased range of motion", "swelling, masses".] • Cardiac: [Insert only if discussed, e.g., “No chest pain", "palpitations", "arrhythmia", "murmur", "edema", "dyspnea", "pacemaker/defibrillator". "Reports 3 stents post arm pain". "No myocardial infarction".] • Gastrointestinal: [Insert only if discussed, e.g., “No nausea/vomiting", "diarrhea", constipation", "melena/hematochezia", "hemorrhoids", "GI ulcer", "hiatal hernia", "incontinence", "weight loss". "Reports reflux".] • Genitourinary: [Insert only if discussed, e.g., “No urgency", "frequency", "dysuria", "hematuria", "incontinence", "slow stream", "urine color change", "scrotal swelling", "vaginal discharge". "Reports nocturia on occasion", "some dribbles", "weaker stream", "and" "kidney stones".] • Integumentary: [Insert only if discussed, e.g., “No dry skin", "rash", "pale skin", "bruising", "abrasions", "ulcers/wounds".] • Head: [Insert only if discussed, e.g., “"No alopecia"] • Respiratory: [Insert only if discussed, e.g., “No shortness of breath", "cough", "pleuritic chest pain", "hemoptysis", "wheezing", "asthma", "pneumonia".] • Musculoskeletal: [Insert only if discussed, e.g., “No gout", "bone pain", "joint pain", "muscle weakness". "Reports arthritis of left thumb".] • Neurologic: [Insert only if discussed, e.g., “No confusion/disorientation", "dizziness", "seizures", "headaches", "memory loss", "abnormal gait", "neuropathy", "unilateral weakness", "paralysis", "stroke/TIA".] • Psychiatric: [Insert only if discussed, e.g., “No hallucinations", "mood swings", "change in sleeping habits", "panic attacks", "anxiety", "depression".] • Performance Status: [Insert Karnofsky or ECOG score if reported] %] 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 in (narrative format)] [Date 2]: [Lab Test and Results in (narrative format)]] RADIOLOGY STUDIES: [Provide details of relevant radiology studies, including the name of the study, dates, findings, and Opinions/Impression/Conclusion of each study if mentioned.] [For example: [Study 1 and Date]: [Detail Findings of everything mentioned about this study in narrative format, including the specific location of each finding and measurements] Opinions/Impression/Conclusion: [If mentioned, write detailed opinion in bullet point format as below] 1. [Opinions/Impression/Conclusion 1] 2. [Opinions/Impression/Conclusion 2] [[Study 2 and Date]: [Detail Findings of everything mentioned about this study in narrative format, including the specific location of each finding and measurements] Opinions/Impression/Conclusion: [If mentioned, write detailed opinion in bullet point format as below] 1. [Opinions/Impression/Conclusion 1]: 2. [Opinions/Impression/Conclusion 2]] PATHOLOGIC STUDIES: [Provide details of relevant pathologic studies, including dates, findings, and conclusions of each study if mentioned.] [For example: [Study 1 and Date]: [Detail Findings of everything mentioned about this study in narrative format] [Conclusion/Comment]: [Detail conclusion or comment] [Study 2 and Date]: [Detail Findings of everything mentioned about this study in narrative format] [Conclusion/Comment]: [Detail conclusion or comment]] SOCIAL HISTORY: [Provide a narrative paragraph detailing the patient's marital status, living situation, occupation, religious preferences, appetite, smoking habits including quantity and duration, and alcohol use including frequency and quantity. Only provide information if specifically ] FAMILY CANCER HISTORY: [Provide details about the patient's family history of cancer, if any. Or state "None that [pronoun] is aware of"] ASSESSMENT: [Provide a detailed assessment of the patient's condition, and clinical impressions. Specify the type of treatment, such as radiotherapy alone or concurrent chemotherapy and radiation therapy. Include details about any scheduled procedures, such as Port-A-Cath placement. Outline the radiotherapy plan. Explain the risks, benefits, possible complications, and side effects of the treatment in depth, and confirm patient consent. Provide details about follow-up appointments, such as CT simulation, and the start of therapy. Mention any scheduled tests or scans, including their purpose. Outline follow-up appointments with healthcare providers, specifying the timeline and any interim consultations.(Narrative Format) PLAN: [Numbered list of all diagnostic tests, medications, radiation plans that will be ordered, and the name of each test.]