Proposed shared H&P for late elective chemotherapy admissions, March 2014
Internal Medicine & Hematology / Oncology
The following will delineate the portions of the H&P each writer will be responsible for.
SAMPLE HISTORY AND PHYSICAL
CC : _____________(Tumor Type) for “elective inpatient treatment involving chemotherapy” ( medicine resident )
HPI : Age, gender, admission for _____ cancer diagnosis and planned cycle _____ of ______ chemotherapy agent or regimen. Brief statement about the patient’s current symptomatology or lack thereof, followed by patient’s current concerns (if present) about the planned regimen ( medicine resident ) .
Details about the patients malignancy – his/her initial presenting symptom or sign with dates, outpatient Oncologist, followed by the diagnostic workup (including molecular, serum, or biopsy based markers if relevant), as well as previous treatments (surgeries, radiation therapies, previous chemotherapy regimens) with side effects or adverse events from previous admissions. If deemed appropriate, a note can be made about the patient’s oncologist, as well any other details decided upon by the subspecialist (oncology fellow) .
ROS : A 10-point ROS must be obtained ( medicine resident )
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Focus should be based on the patient’s past medical history, especially: o infectious diseases (fevers, oral lesions, cough, diarrhea) o hematologic derangements (anemia symptoms or those related to bleeding diatheses) o those related to the patient’s volume status (orthopnea, PND, edema)
PMH : All of the non-malignancy related diagnoses with appropriate detail ( medicine resident )
All of the malignancy-related diagnoses with appropriate detail ( oncology fellow )
Medications : ( medicine resident )
Allergies: ( medicine resident )
Social History:
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Should include information about patient’s social network/circumstances in addition to smoking, ETOH and illicit drug use history ( medicine resident )
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Details about the patient’s ECOG status as appropriate ( oncology fellow )
Family History: ( medicine resident )
Physical Exam: A brief physical exam must be obtained with vital signs ( medicine resident )

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Focus should be placed on finding occult infections, volume status and hematologic abnormalities o Oral lesions, thrush, rales, effusions, JVD, edema o Petechiae, ecchymosis, bleeding
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A complete physical exam (listing 9 sections) must be completed within 24 hours of arrival
( oncology fellow )
Laboratory Data : Routine CBC with differential, complete metabolic panel and coagulation panel must be obtained ( medicine resident )
Imaging: Chest x-ray or other imaging may be obtained as deemed pertinent by the patient’s presentation and/or history ( medicine resident or oncology fellow )
Assessment and Plan: A brief statement stating the patient’s planned cycle of ____chemotherapy for
_____ malignancy diagnosis ( medicine resident ) .
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Any acute problem isolated by the medicine resident: Identify with differential diagnosis, workup and plan. Notify the appropriate parties, consultants, etc. especially if chemotherapy must be delayed ( medicine resident ) .
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Any non-acute, non-malignancy related medical problem: Identify, with comment on its stability, with medication continuation / discontinuation as necessary ( medicine resident ) .
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All malignancy-related diagnoses, work-up and plans as deemed appropriate ( oncology fellow )
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Code status ( medicine resident )