Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Follow-up for cervical cancer, evaluation of new symptoms, or treatment visit (specify).
SOAP
Subjective (S):
History of Present Illness:
Briefly summarize the patient’s diagnosis and stage of cervical cancer.
Inquire about any new or worsening symptoms since the last visit, including:
Pelvic pain or pressure
Vaginal bleeding (unusual amount, spotting, postmenopausal bleeding)
Vaginal discharge (foul-smelling, bloody)
Urinary urgency or frequency
Difficulty passing stool (constipation)
Leg swelling or pain
Fatigue or weight loss
Bowel or urinary incontinence (if applicable)
Sexual dysfunction (if applicable)
Treatment History:
Briefly summarize the patient’s past and current treatment for cervical cancer, including:
Type of surgery (if applicable)
Radiation therapy details (dose, location, side effects)
Chemotherapy details (drugs, cycles, side effects)
Immunotherapy details (type, side effects)
Inquire about adherence to treatment plan and any side effects experienced.
Past Medical History:
Briefly summarize relevant past medical history, including:
Comorbidities that might impact treatment options or prognosis
Previous surgeries or radiation therapy
Objective (O):
Vital Signs:
Record temperature, heart rate, blood pressure, and respiratory rate.
Physical Exam:
Perform a focused physical exam to assess:
General appearance (cachexia, signs of malnutrition)
Pelvic exam:
Appearance of the cervix and vagina
Presence of masses or tenderness
Pelvic lymph node evaluation
Rectal exam (if indicated) to assess for local tumor extension.
Document any abnormal findings.
Imaging Studies (if recent results available):
Briefly mention findings from recent imaging studies (e.g., CT scan, MRI scan, PET scan) if performed, such as:
Evidence of tumor progression, recurrence, or treatment response.
Assessment (A):
Disease Status:
Based on history, physical exam, and imaging findings, assess the current status of the cervical cancer:
Stable disease
Progressive disease
Recurrent disease
Consider response to treatment if applicable.
Symptoms and Side Effects:
Evaluate the patient’s symptoms and potential side effects from treatment.
Plan (P):
Treatment Plan (if applicable):
Depending on the disease status and patient’s condition, outline the treatment plan, which may include:
Continuation or modification of current treatment regimen (surgery, radiation, chemotherapy, immunotherapy)
Supportive care for symptom management (pain management, nutritional support)
Palliative care for advanced disease
Laboratory Tests:
Order necessary laboratory tests as indicated, such as:
Tumor markers (if applicable)
Complete blood count (CBC) to monitor blood cell counts
Electrolytes and kidney function tests
Liver function tests
Imaging Follow-up:
Schedule follow-up imaging studies at appropriate intervals to monitor response to treatment and disease status.
Patient Education:
Address the patient’s concerns and provide education about:
Importance of adherence to treatment plan and follow-up appointments
Expected side effects of treatment and management strategies
Importance of maintaining a healthy lifestyle (diet, exercise)
Sexual health concerns (if applicable)
Support resources available (e.g., patient support groups)
Additional Notes:
Document any other relevant information, such as:
Communication with consulting physicians (e.g., gynecologic oncologist, radiation oncologist, medical oncologist)
Prognosis discussion with the patient and family based on the stage and extent of the disease
Addressing psychosocial concerns related to the diagnosis and treatment
Referral for physical or occupational therapy if needed for rehabilitation
Hospice care considerations for advanced disease