Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Subjective:
Briefly describe the patient’s current voice quality (hoarseness, breathiness, vocal weakness).
Mention any swallowing difficulties or pain.
Inquire about any recent respiratory symptoms (cough, shortness of breath).
Ask about social and emotional impact of the cancer diagnosis (e.g., speech concerns, anxiety).
Objective:
Vital signs: Include temperature, pulse, respiratory rate, blood pressure, oxygen saturation (if on oxygen).
Head and neck exam findings:
Focus on the larynx – palpation for nodules or masses, mobility of vocal cords (indirect laryngoscopy if possible).
Examine lymph nodes in the neck for enlargement.
Imaging results (if recent): Briefly describe findings from relevant imaging studies (e.g., CT scan, MRI) related to the laryngeal cancer.
Assessment:
Restate the diagnosis of laryngeal cancer.
Mention the current disease stage based on recent workup (TNM classification).
Include laterality (which side of the larynx is involved).
Plan:
Treatment plan update:
Summarize the current treatment plan (surgery, radiation therapy, chemotherapy, or a combination).
Mention any upcoming treatment phases or potential modifications.
Speech and swallowing therapy:
If applicable, outline recommended speech and swallowing rehabilitation plan.
Nutritional assessment:
Document any need for dietary modifications or feeding tube placement.
Follow-up:
Specify the schedule for upcoming clinic visits, imaging studies, or endoscopy procedures.
Notes:
Include any additional relevant information not captured in other sections.
Document discussions with the patient and family regarding treatment options, potential side effects, and prognosis.
Mention any referrals to other specialists (e.g., speech therapist, dietician).