Summary

Patient: 
Attending:
Fellow: 

Cancer Diagnosis: 

Active Treatment: 

Subjective

Chief Concern: cancer follow up

Interim Chart Review: 

Interim History: 

Oncology Timeline: 

- Initial History: 

- Biopsy: 

- Initial Staging: 

- First Treatment: 

- FOLFOX

C1

Medical History: 

Surgical History: 

Family History: 

Social History: 

Allergies: 

Medications:  

Objective

Vitals:  

Exam: 

Labs: 

Imaging: 

Pathology: 

Assessment/Plan

#Cancer

-stage at diagnosis: 

-

-intent: 

#Health Maintenance and Cancer Screenings

-Lung cancer screening: for adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years

-AAA screening: 1-time screening for abdominal aortic aneurysm (AAA) with ultrasonography in men aged 65 to 75 years who have ever smoked.

-CRC screening: ages 45-49 (B) especially if Black race, ages 50-75 (A), ages 76-85 (C) more benefit with never screened. Stool DNA-FIT every 1 to 3 years | CT colonography every 5 years | Flexible sigmoidoscopy every 5 years | Flexible sigmoidoscopy every 10 years + annual FIT | Colonoscopy screening every 10 years

Orders: 

-labs: 

-return to clinic: 

USPSTF

Example Note

Summary

Patient: 
Attending:
Fellow: 

Cancer Diagnosis: 

Active Treatment: 

Subjective

Chief Concern: cancer follow up

Interim Chart Review: 

Interim History: 

Oncology Timeline: 

- Initial History: 

- Biopsy: 

- Initial Staging: AJCC IIa

- First Treatment: Chemotherapy

- FOLFOX

C1: 7/13/25

C2: 7/27/25 - experienced diarrhea, grade 2 

C3: 8/10/25

C4: 8/24/25

C5: 9/7/25

C6: 9/21/25

-Recurrence via CT 12/4/25 

Medical History: 

Surgical History: 

Family History: 

Social History: 

Allergies: 

Medications:  

Objective

Vitals:  

Exam: 

General: cooperative, no acute distress

HEENT: EOMI, not icteric. External ears normal. No rhinorrhea. Moist mucous membranes.

Neck: Supple, full range of motion, no observable masses.

Lungs: Clear to auscultation bilateral, no wheezing.

CV: RRR, no edema.

Abdomen: Soft, non-tender, non-distended.

Extremities: No joint swelling, no redness, no pittig edema

Skin: No rashes, petechiae, lesions. Normal color per patient.

Neuro: Normal Gait, Grossly intact.

Psych: Appropriate for situation.

Labs: 

Imaging: 

Pathology: 

Assessment/Plan

#Cancer

-stage at diagnosis: 

-

-intent: 

#Cancer Screenings

-Lung cancer screening: for adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years

-AAA screening: 1-time screening for abdominal aortic aneurysm (AAA) with ultrasonography in men aged 65 to 75 years who have ever smoked.

-CRC screening: ages 45-49 (B) especially if Black race, ages 50-75 (A), ages 76-85 (C) more benefit with never screened. Stool DNA-FIT every 1 to 3 years | CT colonography every 5 years | Flexible sigmoidoscopy every 5 years | Flexible sigmoidoscopy every 10 years + annual FIT | Colonoscopy screening every 10 years

Orders: 

-labs: 

-return to clinic: