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Oncologist Template

First Oncology Consultation

A professional Oncologist template for healthcare professionals.
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About this template

This "First Oncology Consultation" template is an essential tool for oncologists and oncology nurses during initial patient assessments. Designed to capture comprehensive information, it streamlines the documentation of critical details such as oncology diagnosis with ICD-10 codes, cancer stage, date of diagnosis, and extensive patient history including social, medical, surgical, and family backgrounds. Clinicians will find it invaluable for detailing current illness, presenting complaints, and results from clinical examinations, special investigations, imaging, histology, blood tests, and NGS. With Heidi, this template efficiently organises complex patient data from your consultation, ensuring a thorough assessment and clear management plan for every new oncology patient. It’s perfect for creating detailed, structured records that support effective cancer care.

Preview template

Clinician Specialty: Oncologist Patient name and age: Jane Doe, 62 years old Referring Doctor: Dr. Sarah Chen Copy Doctor: Dr. Michael Green Oncology diagnosis and ICD-10 code: Invasive ductal carcinoma of breast, Stage IIB (C50.911) Stage: Stage IIB Date of diagnosis: 1 November 2024 Social history: Married, lives with husband. Works as a retired teacher. Occasional social drinker, non-smoker. No illicit drug use. Allergies: Pencillin (rash, pruritus) (T42.0X5A) Smoking history: Never smoked (Z87.891) Alcohol history: Occasional social drinker, 1-2 units per week (Z72.89) Previous medical history: Hypertension (I10), Type 2 Diabetes Mellitus (E11.9) Previous surgical history: Appendectomy (2005), Cholecystectomy (2015) Family history: Mother diagnosed with breast cancer at age 70. Father died of myocardial infarction at age 65. Current illness: Patient presented with a palpable lump in her right breast approximately three months ago. Mammogram and subsequent biopsy confirmed invasive ductal carcinoma. She reports no nipple discharge or skin changes. Occasional mild breast pain, but denies systemic symptoms like weight loss or fever. Presenting complaints: Right breast lump, mild breast pain. Surgery to date for current referral: Core needle biopsy of right breast mass on 15 October 2024. Clinical examination: General: Well-nourished, no acute distress. Vital signs stable. Breasts: Right breast, 2.5 cm firm, mobile mass palpable in the upper outer quadrant, non-tender. No skin dimpling, erythema, or nipple retraction. Left breast, no palpable masses or abnormalities. Axillary lymph nodes: No palpable lymphadenopathy in either axilla. Supraclavicular nodes: Not enlarged. Special investigations: Mammogram, Ultrasound of breast, CT chest/abdomen/pelvis, Bone scan. Imaging: Mammogram: Irregular speculated mass, 2.3 cm, in the right upper outer quadrant. BI-RADS 5. Ultrasound: Corresponding hypoechoic mass with ill-defined margins. No suspicious axillary lymph nodes identified. CT chest/abdomen/pelvis: No evidence of distant metastases. Bone scan: No evidence of bony metastases. Histology: Invasive ductal carcinoma, oestrogen receptor positive, progesterone receptor positive, HER2 negative. Blood results: Full blood count: WNL. Liver function tests: WNL. Renal function tests: WNL. Tumour markers (CA 15-3): Within normal limits. NGS: No specific actionable mutations identified in BRCA1/2, TP53, or ATM. Testing for PIK3CA mutation pending. Assessment: 62-year-old female with newly diagnosed Stage IIB (T2N0M0) hormone-receptor positive, HER2-negative invasive ductal carcinoma of the right breast. Patient is otherwise fit and well with controlled co-morbidities. Risk of recurrence is moderate based on tumour characteristics. Plan: 1. Discussion at multidisciplinary team meeting. 2. Recommend neoadjuvant chemotherapy given tumour size, followed by lumpectomy and sentinel lymph node biopsy. 3. Consider genetic counselling. 4. Commence endocrine therapy following surgery. 5. Follow-up appointment in 2 weeks to discuss MDT recommendations and treatment plan in detail. Prescribe antiemetics and instruct on potential chemotherapy side effects. Key takeaway: Patient requires neoadjuvant chemotherapy followed by surgery and endocrine therapy for Stage IIB breast cancer.
Patient name and age: [Insert patient name and age] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Referring Doctor: [Insert referring doctor name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Copy Doctor: [Insert copy doctor name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Oncology diagnosis and ICD-10 code: [Insert oncology diagnosis with ICD-10 code] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Stage: [Insert cancer stage] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Date of diagnosis: [Insert date of diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Social history: [Insert relevant social history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Allergies: [Insert allergies with ICD-10 codes if provided] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Smoking history: [Insert smoking history with ICD-10 code if provided] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Alcohol history: [Insert alcohol history with ICD-10 code if provided] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Previous medical history: [Insert previous medical conditions with ICD-10 codes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Previous surgical history: [Insert previous surgical history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Family history: [Insert relevant family history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Current illness: [Insert summary of current illness] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Presenting complaints: [Insert presenting complaints] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Surgery to date for current referral: [Insert surgeries performed related to current referral] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Clinical examination: [Insert clinical examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Special investigations: [Insert special investigations performed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Imaging: [Insert imaging findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Histology: [Insert histology results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Blood results: [Insert blood results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) NGS: [Insert next-generation sequencing results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Assessment: [Insert assessment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Plan: [Insert management plan] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Key takeaway: [Insert key takeaway or summary point] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (For each section, only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the section entirely. Never come up with your own patient details, diagnoses, staging, investigations, assessment, plan, or conclusions—use only the transcript, contextual notes, or clinical note as the source of truth. If any information related to a placeholder has not been explicitly mentioned, do not state that it is missing; simply omit the placeholder or section entirely. Never hallucinate.)
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Specialty

Oncologist

Used

15 times

Type

Note

Last edited

1/13/2026

Created by

Redmund Nel

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