ProCLIPS Dictation Format Notes

FOLLOW-UP NOTE FORMAT

This is Dr. [YOUR NAME] dictating a FOLLOW-UP note on [PATIENT'S FULL NAME], hospital number is [HOSPITAL NUMBER]. Today's date is [TODAYS DATE].

(for residents and fellows only)
The Attending physician is [ATTENDING's NAME]

**STATUSES:

Overall status is [OVERALL STATUS] and the status date is [OVERALL STATUS DATE].
Local status is [LOCAL STATUS] and the local status date is [LOCAL STATUS DATE],
Distant status is [DISTANT STATUS] and the distant status date is [DISTANT STATUS DATE]

(for patients who have complications)
Complication(s) are [COMPLICATION(S)] Complication date [COMPLICATION DATE]

(for patients who have died) [DEATH DATE]

*Interval since completion of therapy: [TIME INTERVAL] (up to 2).
*Region treated: [RADIATION REGON] (1 region per INTERVAL)

Narrative: [Current patient situation, outcome and response to therapy, complications, further therapy, and follow-up plans]

(for residents/fellows only) The patient was seen jointly by Dr. [RESIDENT'S NAME] and Dr. [ATTENDING'S NAME]

(necessary only when different from H & P) Copies to: [PRIMARY REF MD - 1st & last NAME] [REF MDs 2 -5 - 1st & last NAMES]

COMPLETION SUMMARY FORMAT

This is Dr. [YOUR NAME] dictating a Completion Summary on [PATIENT'S FULL NAME], today's date is [TODAYS DATE], the patient's hospital number is [HOSPITAL NUMBER]. The Attending physician is [ATTENDING's NAME]

Primary diagnositic information - This is the diagnosis for which the patient has been referred - only necessary if different from that in H&P)
Their histology and location are: [HISTOLOGY + LOCATION] The Diagnosis Date is [EXACT DIAGNOSIS DATE] Disease Stage is T Stage [T-STAGE] N Stage [N STAGE] M Stage [M STAGE] Overall Stage is (I-IV...) [STAGE]
The secondary diagnosis is: (only necessary for patients with previous or second diagnosis when different from that in most recent H&P or RECONSULTATION note.)
Primary and other referring physicians are: (necessary only when different from H & P) [PRIME REF MD - 1st & last NAME] [REF MD 2 - 5 - 1st & last NAMES]
History Summary: The patient is a [AGE][RACE][GENDER]... [Summary of HISTORY including AGE RACE, and GENDER,... along with pertinent reason for referral + treatment as well as treatment plan and objectives. This should NOT be copied from a STAFF NOTE!]
Summary of Radiation Fields: (unlimited number) [TREATED REGION] [ENERGY] [DOSE (cGy)] [FROM DATE] [TO DATE] [FRACTIONS]
Summary of Radiation Course: [Narrative of technical radiation course, patient course during therapy, concurrent therapy, end of therapy exam, and follow-up plan]
(for residents/fellows only) The patient was seen jointly by Dr. [RESIDENT'S NAME] and Dr. [ATTENDING'S NAME]

RECONSULT NOTE FORMAT

This is Dr. [YOUR NAME] dictating a RECONSULT note on [PATIENT'S FULL NAME], hospital number [HOSPITAL NUMBER], today's date is [TODAY'S DATE]

(for residents and fellows only)
The Attending physician is [ATTENDING's NAME]
Primary diagnositic information: (this is the diagnosis for which the patient has been referral)
Their histology and location are: (This information is always necessary even if same as that in last EOT or H&P) [HISTOLOGY + LOCATION] The Diagnosis Date is [EXACT DIAGNOSIS DATE] Disease Stage is T Stage [T-STAGE] N Stage [N STAGE] M Stage [M STAGE] Overall Stage is (I-IV...) [STAGE]
The secondary diagnosis is: (only necessary for patients with previous or second diagnosis when different from that in last EOT or H &P)

**STATUSES:
Exact same as STATUSES in FOLLOW-UP NOTE FORMAT
*INTERVALS:
*Interval since completion of therapy: [TIME INTERVAL] (up to 2).
*Region treated: [RADIATION REGON] (1 region per INTERVAL)

History: The patient is a [AGE][RACE][GENDER] [COMPLETE HISTORY +PHYSICAL EXAM... IMPRESSION and PLAN]

(for residents/fellows only)
The patient was seen jointly by Dr. [RESIDENT'S NAME] and Dr. [ATTENDING'S NAME]

Thank you, Dr. [PRIMARY REFERRING MD] for asking us to see this patient. Copies to: (necessary only when different from H & P) [PRIME REF MD - 1st & last NAME] [REF MDs 2 - 5- 1st & last NAMES]

STAFF START NOTE (CORRESPONDENCE NOTE)

This is Dr. [YOUR NAME] dictating a STAFF NOTE on [PATIENT'S FULL NAME], hospital number [HOSPITAL NUMBER], today's date is [TODAY'S DATE].
Narrative: [Free text narrative of your choice]

INTERIM NOTES: Use same format as for FOLLOW-UP notes. The INTERVAL FROM COMPLETION OF THERAPY is left blank.
DEATH NOTES: These should be dictated as FOLLOWUP NOTES in the case of a patient who has been treated, or INTERIM NOTES in the case of a patient who has not been treated.

**STATUSES EXPLAINED:
  OVERALL: Refers to overall condition of patient
  LOCAL: Status of disease within the radiation field.
  DISTANT: Refers to status outside the radiation field.

AWD: Alive With Disease. Used with reference to OVERALL STATUS.
NED: No Evidence of Disease. Used with reference to OVERALL, LOCAL and DISTANT statuses.
NEPD: Stable abnormailty present or without clinical and/or radiographic evidence of progression or relapse. Synonymous with STABLE.
REL: Relapse or progression of disease. Used with reference to OVERALL, LOCAL and DISTANT statuses.
PD: Progressive Disease. Used with reference to OVERALL, LOCAL and DISTANT statuses. Generally denoted for patientswho had had previous stable abnormalities and had been designated NEPD or STABLE.

* Though INTERVALS and REGIONS are automatically calculated and entered by ProCLIPS, it is always best to dictate these data.