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Oncology Follow-Up Note Cancer History / Context - Primary diagnosis, histology, stage, molecular markers as relevant, and current treatment intent. - Line of therapy and cycle day / days on oral therapy / time since last treatment or surgery/radiation. Interval History - Disease-related symptoms (pain, masses, cough, neurologic symptoms, bleeding, constitutional symptoms). - Treatment tolerance and toxicities by system (heme, GI, skin, neuropathy, endocrine, immune-related AEs). - Performance status change, hospitalizations, infections, transfusions, and supportive-care needs. - Adherence for oral therapies; missed doses and reasons. Data Reviewed - Labs (CBC, CMP, tumor markers), imaging/response assessment, pathology, and outside oncology records discussed today. - ECOG/Karnofsky if assessed. Exam - Focused exam including performance status, relevant nodes/masses, cardiopulmonary, and toxicity-related findings. Assessment - Disease status (responding / stable / progressing / NED on surveillance). - Treatment tolerance and active toxicities with grade if used. - Active supportive-care problems. Plan - Continue, hold, dose-reduce, delay, or change antineoplastic therapy with rationale. - Supportive medications, growth factors, infection workup, referrals (palliative care, radiation, surgery, cardio-onc). - Next imaging/labs, infusion scheduling, and precautions (fever neutropenia, irAE warning signs). - Goals-of-care or prognosis discussion if held today.
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- Keeps cancer diagnosis, stage/line of therapy, and intent (curative/palliative) visible.
- Separates disease response from treatment toxicity in the interval story.
- Supports chemo, immunotherapy, targeted therapy, and survivorship follow-ups.
- Documents goals-of-care touchpoints without forcing a full goals visit format.
- 1Medical oncology treatment follow-ups
- 2Oral oncolytic monitoring visits
- 3Cancer surveillance and survivorship visits
Example output shape
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Cancer Context Stage IIIA NSCLC, adenocarcinoma, PD-L1 60%, EGFR/ALK negative. Completing adjuvant pembrolizumab; currently cycle 8, day 1. Curative-intent pathway post-resection/chemo. Interval History Mild fatigue; no new cough, hemoptysis, or chest pain. Pruritus improved on topical steroid. No diarrhea, dyspnea, or vision changes. ECOG 1. Adherent; no missed doses. Data Reviewed CBC/CMP today acceptable for treatment. CT chest/abdomen/pelvis 3 weeks ago: no recurrence. TSH normal last month. Exam ECOG 1. Lungs clear, well-healed thoracotomy scar, no new lymphadenopathy. Skin: faint eczema antecubitals. Assessment NED on adjuvant pembrolizumab; well tolerated with mild dermatitis controlled. Plan Proceed with pembrolizumab today. Continue topical triamcinolone PRN. Educate on irAE red flags (severe diarrhea, SOB, chest pain, severe headache). Labs before next cycle. Restage imaging in ~3 months. Follow up next cycle; call clinic for fever ≥100.4 or new severe symptoms.
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