Top 10 Clinical Note Templates Used by Oncologists in 2025

Which Documentation Templates Support Comprehensive Cancer Care and Treatment Monitoring?

Oncology practitioners face unparalleled documentation demands that span initial diagnosis, multidisciplinary treatment planning, systemic therapy administration, and long-term survivorship management. To maintain clinical excellence, regulatory compliance, and seamless team communication, leading oncology practices in 2025 rely on a core set of specialized note templates. These templates integrate evidence-based assessments, precision medicine data, and patient-reported outcomes, streamlining workflows and enhancing care quality across the cancer continuum. 

 

 

Rank	Template Name	Usage Frequency	Key Components
1	Oncology SOAP Note Template	Daily (90%)	- Tumor marker trends (CEA, CA-125, PSA) - Performance status (ECOG/Karnofsky) - Symptom assessment scales (pain, fatigue) - Interim treatment response (RECIST 1.1) and toxicity summary
2	Chemotherapy Administration Note	Daily (85%)	- Regimen details with cycle and day number - Pre-medication protocols (antiemetic, corticosteroid) - Infusion logs (vital signs, infusion rates) - CTCAE adverse event grading
3	Tumor Board Presentation Template	Weekly (70%)	- Pathology review (histology, immunohistochemistry, molecular markers) - Staging summary with TNM and AJCC v9 - Multidisciplinary treatment options - Clinical trial eligibility
4	Radiation Oncology Consultation	Weekly (60%)	- Target volumes and radiation fields - Dose fractionation details (Gy/fraction) - Treatment planning notes (beam angles, organ-at-risk constraints) - Toxicity monitoring
5	Cancer Staging Documentation	Weekly (65%)	- TNM staging input fields - Biomarker results (PD-L1, MSI, HER2) - Genetic testing summary (BRCA, NTRK fusions) - Prognostic factor checklist (age, comorbidities)
6	Palliative Care Consultation	Weekly (45%)	- Symptom management plan (opioid, adjuvant analgesics) - Goals of care and advance directive notes - Psychosocial/spiritual support assessment - Family meeting summaries
7	Immunotherapy Follow-Up Template	Weekly (50%)	- Immune-related adverse event monitoring (pneumonitis, colitis) - Response assessment (iRECIST) - Biomarker monitoring (LDH, lymphocyte counts) - Steroid taper plans
8	Oncologic Emergency Note	As needed	- Urgent complication triage (tumor lysis syndrome, neutropenic fever) - Intervention timeline (IV hydration, antibiotics) - MASCC score for febrile neutropenia - Disposition plan
9	Survivorship Care Plan Template	Monthly (35%)	- Long-term effects monitoring (cardiotoxicity, neuropathy) - Surveillance schedules (imaging, labs) - Wellness recommendations (diet, exercise) - Second malignancy screening
10	Clinical Trial Documentation	Monthly (40%)	- Protocol adherence checklists - Adverse event reporting (CTCAE grades) - Efficacy assessments (PFS, ORR) - Informed consent tracking and IRB communication logs

 

 

 

 

 

Detailed Insights Into Key Templates

1. Oncology SOAP Note Template
This versatile template forms the backbone of daily oncology encounters. It seamlessly integrates laboratory data—such as trending tumor markers (e.g., CEA in colorectal cancer, CA-125 in ovarian cancer, PSA in prostate cancer)—with performance status assessments using ECOG or Karnofsky scales. The subjective section prompts clinicians to quantify pain, fatigue, and quality-of-life factors using validated scales. The objective section pulls in the latest imaging reports, while the assessment area embeds RECIST 1.1 criteria to classify treatment response consistently. Finally, the plan section auto-generates follow-up scheduling reminders and toxicity management orders, ensuring comprehensive documentation of each therapy cycle.

2. Chemotherapy Administration Note
Designed for treatment infusion settings, this template captures granular details of chemotherapy delivery. Clinicians document regimen specifics (e.g., FOLFOX cycle 3, day 2), premedication protocols including antiemetic dosing and steroid schedules, and real-time infusion logs detailing vital signs and pump rates. A dedicated section for CTCAE adverse event grading ensures immediate capture of any infusion-related reactions—such as hypersensitivity, mucositis, or neutropenia—alongside automated dose modification suggestions based on institutional guidelines.

3. Tumor Board Presentation Template
Tumor boards require concise yet comprehensive case summaries. This template aggregates pathology findings (histologic subtype, immunohistochemistry results, key molecular markers like EGFR or ALK in lung cancer), TNM staging with AJCC v9 references, and radiology correlations from PET/CT. It then outlines potential multidisciplinary treatment pathways—surgical resection, radiation consolidation, systemic therapy options—and flags clinical trial eligibility using inclusion/exclusion criteria checklists. The consensus recommendations section captures the multi-specialty discussion outcome, streamlining implementation of the agreed plan.

4. Radiation Oncology Consultation
This template supports radiation oncologists by automating technical parameter documentation. Clinicians input target volumes with standardized contour labels, specify dose fractionation (e.g., 60 Gy in 30 fractions), and note beam arrangement details. Organ-at-risk constraints—such as lung V20 or spinal cord Dmax—are pulled from treatment planning software into the note. Weekly toxicity monitoring fields prompt evaluation of acute side effects like dermatitis and mucositis, ensuring prompt supportive care ordering within the same interface.

5. Cancer Staging Documentation
Accurate staging is vital for prognosis and treatment selection. This template features structured TNM input fields linked to AJCC staging manuals, with built-in references for staging criteria. It captures biomarker results—PD-L1 expression levels, MSI status, HER2 amplification—and genetic test summaries including BRCA, NTRK, or mismatch repair deficiency. A prognostic factor checklist ensures documentation of age, performance status, and significant comorbidities, facilitating risk stratification and multidisciplinary care planning.

6. Palliative Care Consultation
Palliative oncology requires careful documentation of complex symptom management and care goals. This template guides clinicians through comprehensive assessments—pain control plans with opioid conversions and adjuvant analgesics, non-pharmacologic interventions, and psychosocial support needs. Advance directive discussions, family meeting summaries, and hospice referrals are standardized with sign-off fields. Embedding quality-of-life scales (e.g., ESAS) ensures systematic symptom tracking over time.

7. Immunotherapy Follow-Up Template
Immuno-oncology introduces unique adverse event profiles requiring vigilant monitoring. This template includes immune-related toxicity checklists—such as pneumonitis, colitis, endocrinopathies—mapped to CTCAE grading. It supports response assessments per iRECIST guidelines, capturing pseudoprogression scenarios. Biomarker monitoring fields track LDH levels and lymphocyte counts as potential efficacy correlates. Steroid taper sections and immunosuppressive therapy notes ensure safe management of severe immune-mediated events.

8. Oncologic Emergency Note
Rapid identification and management of oncologic emergencies—tumor lysis syndrome, neutropenic sepsis, spinal cord compression—are critical. This template provides triage severity scales, immediate intervention timelines (IV fluids, rasburicase), and risk stratification using MASCC scores. Disposition planning fields coordinate inpatient admission or ICU transfer with oncology-hematology vs. acute care teams, ensuring seamless transitions and documentation of urgent care protocols.

9. Survivorship Care Plan Template
As patients transition beyond active treatment, this template ensures long-term follow-up for late effects—cardiotoxicity surveillance with echocardiogram scheduling, neuropathy assessments using CTCAE scales, and monitoring for secondary malignancies. Wellness recommendations include nutrition, exercise, and psychosocial support referrals. Surveillance schedule fields automatically generate reminders for annual imaging and lab testing, supporting compliance with NCCN survivorship guidelines.

10. Clinical Trial Documentation
Trial protocols demand stringent documentation to meet regulatory and IRB requirements. This template features protocol adherence checklists, systematic adverse event reporting aligned with CTCAE terminology, and efficacy assessments capturing progression-free and overall response metrics. It integrates informed consent tracking with timestamped signatures and IRB communication logs, ensuring complete audit trails and data integrity for clinical research operations.

 

Advanced Integration and Continuous Optimization

• AI Scribe Integration: Implementing AI scribes like S10.AI streamlines these templates by auto-populating structured fields from clinician-patient dialogues, reducing manual data entry and transcription errors.
• EHR Embedded Decision Support: Templates integrated with EHR-based clinical decision support tools automatically prompt guideline-based interventions, such as dose modifications for toxicity or referrals for genetic counseling.
• Data Analytics Dashboards: Real-time reporting on template usage, treatment outcomes, and adverse event frequencies enables oncology practices to monitor quality metrics and identify areas for workflow optimization.
• Patient Portal Connectivity: Survivorship and follow-up templates link directly to patient portals, delivering tailored care plans, educational resources, and appointment scheduling options that foster patient engagement and adherence.

By adopting these specialized oncology note templates and leveraging AI-driven documentation assistants, cancer care teams can elevate clinical efficiency, enhance multidisciplinary collaboration, and deliver personalized, guideline-driven care that meets the demands of modern oncology practice.