Oncology Progress Note

Finished note

Example — generated by Notat from a sample visit

Reason for consultation:
Review of gradually worsening exertional breathlessness over two months. No chest pain at rest or syncope.

Assessment:
Stable clinical presentation requiring further outpatient evaluation.

Plan:
Arrange relevant investigations, continue current medicines, and advise urgent assessment for chest pain, fainting, or breathlessness at rest.

Clinical documentation:
Relevant symptoms, meaningful negatives, assessment, and follow-up advice were captured from the sample visit and organised into the selected template.

FactsContext™

Template

Oncology Note

Patient Identification: [Patient name, age, gender, relevant oncologic history, presenting complaint]

History of Present Illness:
[Detailed description of presenting symptoms, onset, duration, progression, associated features, prior treatments, and response]

Past Medical History:
(hyphenated list)
- [Relevant medical conditions, including prior malignancies, comorbidities]

Surgical History:
(hyphenated list)
- [Prior surgeries, dates, indications]

Medications:
(hyphenated list)
- [Medication name, dose, route, frequency]

Allergies:
(hyphenated list)
- [Drug/agent and reaction]

Family History:
(hyphenated list)
- [Relevant family history of cancer or genetic syndromes]

Social History:
(hyphenated list)
- [Tobacco: type, amount, duration, quit date if applicable]
- [Alcohol: type, amount, frequency]
- [Recreational substances: type, amount, frequency]
- [Occupation: current job, exposures]
- [Living situation: who lives with patient, home environment]
- [Support system]

Review of Systems:
(hyphenated list)
- [Pertinent positives and negatives by system]

Physical Examination:
(hyphenated list)
- [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)
- [General appearance]
- [HEENT: findings]
- [Cardiovascular: findings]
- [Respiratory: findings]
- [Abdomen: findings]
- [Lymph nodes: findings]
- [Skin: findings]
- [Neurological: findings]
- [Other relevant systems]

Investigations:
(hyphenated list)
- [Laboratory results with units]
- [Imaging findings]
- [Pathology reports]
- [Other relevant studies]

Assessment & Plan:
[One-sentence patient summary including age, sex, cancer diagnosis, stage, and performance status]

#) [Diagnosis or problem as a numbered item]
(hyphenated list with each corresponding plan item on a new line)
- [Staging and prognosis]
- [Treatment plan: chemotherapy, radiation, surgery, targeted therapy, immunotherapy]
- [Symptom management and supportive care]
- [Counselling and goals of care discussion]
- [Referrals to other specialties or services]
- [Follow up plan]
- [Return precautions]