Oncology: Step-by-Step Guide on How to Write SOAP Notes

Updated January 2026

Oncology documentation demands exceptional precision, comprehensive detail, and strict adherence to evidence-based protocols. Cancer care SOAP notes must capture complex staging information, treatment regimens, toxicity assessments, and response evaluations while supporting multidisciplinary coordination and clinical trial compliance. This guide provides comprehensive instructions for documenting oncology encounters, from initial diagnosis through treatment and survivorship, ensuring compliance with NCCN guidelines and optimal patient care.

What Makes Oncology Documentation Unique

Oncology documentation differs from other specialties in several critical ways:

1. Cancer Staging: Documentation must precisely capture TNM staging, histopathologic features, and molecular/genomic markers essential for treatment planning
2. Treatment Protocols: Chemotherapy, immunotherapy, and targeted therapy regimens require exact documentation of drugs, doses, cycles, and modifications
3. Toxicity Monitoring: Systematic assessment and grading of treatment-related adverse events using CTCAE (Common Terminology Criteria for Adverse Events)
4. Response Assessment: Standardized evaluation using RECIST criteria for solid tumors or disease-specific response criteria
5. Performance Status: Regular documentation of ECOG or Karnofsky performance status to guide treatment decisions
6. Survivorship Care: Long-term monitoring for late effects, secondary malignancies, and quality of life
7. Clinical Trial Documentation: Rigorous documentation requirements for patients enrolled in research protocols
8. Multidisciplinary Coordination: Integration of surgery, radiation, and medical oncology treatment plans

Subjective Section (S)

The Subjective section in oncology captures treatment tolerance, symptom burden, functional status, and psychosocial factors essential for cancer care management.

Subjective Section (S) Components

1. Chief Complaint:

   • Primary reason for visit (treatment, surveillance, symptom management)
   • Current point in treatment course
   • Example: "Cycle 4 Day 1 of FOLFOX chemotherapy for stage III colon cancer"

2. Treatment Tolerance Assessment:

   • How patient tolerated previous treatment cycle
   • New or worsening symptoms since last treatment
   • Symptom severity and impact on function
   • Example: "Patient reports moderate fatigue for 5 days following last cycle, resolved by day 10. Mild nausea controlled with ondansetron."

3. Symptom Assessment with CTCAE Grading: Document each symptom with severity grade:

   • Grade 1: Mild; asymptomatic or mild symptoms
   • Grade 2: Moderate; minimal intervention indicated
   • Grade 3: Severe; medically significant, hospitalization indicated
   • Grade 4: Life-threatening; urgent intervention indicated
   • Grade 5: Death related to adverse event

   Common symptoms to assess:

   • Fatigue: Severity, duration, impact on ADLs
   • Nausea/Vomiting: Frequency, triggers, response to antiemetics
   • Neuropathy: Location, character (numbness, tingling, pain), functional impact
   • Mucositis/Stomatitis: Severity, impact on oral intake
   • Diarrhea/Constipation: Frequency, volume, need for intervention
   • Myelosuppression symptoms: Infections, bleeding, fatigue from anemia
   • Skin reactions: Rash, hand-foot syndrome, nail changes
   • Cognitive changes: "Chemo brain," concentration difficulties

   Example: "Peripheral neuropathy - Grade 2: Moderate symptoms limiting instrumental ADLs (difficulty with buttons, writing). Numbness and tingling in fingertips and toes bilaterally, present since cycle 3."

4. Functional Status Assessment:

   ECOG Performance Status:

   • 0: Fully active, no restrictions
   • 1: Restricted in strenuous activity, ambulatory, light work capable
   • 2: Ambulatory, capable of self-care, unable to work, up >50% of waking hours
   • 3: Capable of limited self-care, confined to bed/chair >50% of waking hours
   • 4: Completely disabled, no self-care, totally confined to bed/chair
   • 5: Dead

   Karnofsky Performance Status (alternative scale, 0-100%):

   • 100: Normal, no complaints
   • 90: Able to carry on normal activity; minor signs/symptoms
   • 80: Normal activity with effort; some signs/symptoms
   • 70: Cares for self; unable to carry on normal activity
   • 60: Requires occasional assistance but cares for most needs
   • 50: Requires considerable assistance and frequent medical care
   • 40: Disabled; requires special care and assistance
   • 30: Severely disabled; hospitalization indicated
   • 20: Very sick; active supportive treatment necessary
   • 10: Moribund

   Example: "ECOG Performance Status: 1 (baseline 0). Patient reports increased fatigue limiting ability to exercise but continues working part-time from home."

5. Nutritional Status:

   • Current weight and weight change
   • Appetite assessment
   • Dietary intake adequacy
   • Need for nutritional support
   • Example: "Weight 165 lbs, down 8 lbs (4.6%) from treatment start. Appetite decreased, eating approximately 50% of usual intake. No dysphagia. Using nutritional supplements twice daily."

6. Pain Assessment:

   • Location, quality, intensity (0-10 scale)
   • Cancer-related vs. treatment-related
   • Current pain regimen and effectiveness
   • Breakthrough pain frequency
   • Example: "Right hip pain 6/10, constant, aching quality. Known bone metastasis. Currently on extended-release morphine 30mg BID with morphine IR 15mg for breakthrough (using 2-3 doses daily). Partial relief with current regimen."

7. Psychosocial Assessment:

   • Emotional coping and adjustment
   • Anxiety and depression screening
   • Social support system
   • Financial/insurance concerns
   • Work/functional impact
   • Caregiver burden
   • Example: "Patient reports increased anxiety regarding upcoming restaging scans. PHQ-2 positive, PHQ-9 score 12 (moderate depression). Living with spouse who provides good support. Concerned about medical expenses despite insurance coverage."

8. Review of Systems (Cancer-Focused):

   • Constitutional: Fever, night sweats, weight loss
   • New or changing masses
   • Neurological symptoms (concerning for CNS involvement)
   • Respiratory symptoms (pulmonary metastases, effusions)
   • GI symptoms (obstruction, bleeding)
   • Bone pain (metastatic disease)

9. Medication Review:

   • Current chemotherapy/immunotherapy regimen
   • Supportive medications (antiemetics, growth factors, pain management)
   • Adherence to oral oncolytics if applicable
   • OTC medications and supplements
   • Example: "Current regimen: FOLFOX (cycle 4). Supportive meds: Ondansetron 8mg TID PRN, dexamethasone per protocol, pegfilgrastim day 2. Taking all medications as prescribed."

Example Subjective Section for Oncology

Objective Section (O)

The oncology Objective section requires comprehensive physical examination with attention to treatment-related effects, performance status verification, tumor markers, and imaging results.

Objective Section (O) Components

1. Vital Signs:

   • Blood pressure, heart rate, temperature
   • Respiratory rate, oxygen saturation
   • Weight with comparison to prior visits
   • Height (for BSA calculation)
   • Body Surface Area (BSA) for dosing
   • Example: "BP 128/78, HR 72, Temp 98.4F, RR 16, SpO2 98% RA. Weight 172 lbs (78 kg), Height 5'10' (178 cm), BSA 1.96 m2"

2. Performance Status (Verified):

   • ECOG score with supporting observations
   • Comparison to baseline and prior visits
   • Example: "ECOG 1: Patient walked independently to exam room, appears mildly fatigued but in no distress. Baseline ECOG 0."

3. General Appearance:

   • Overall condition
   • Nutritional status
   • Signs of distress
   • Example: "Alert, well-groomed male appearing stated age. Mild pallor. No acute distress. Appears well-nourished despite modest weight loss."

4. Treatment-Specific Physical Examination:

   Port/Central Line Assessment:

   • Site inspection (erythema, swelling, drainage)
   • Patency verification
   • Example: "Right chest port site: Well-healed, no erythema, warmth, tenderness, or drainage. Port accessed without difficulty, good blood return."

   Neuropathy Assessment:

   • Sensory examination (light touch, pinprick, vibration)
   • Motor strength testing
   • Deep tendon reflexes
   • Functional assessment
   • Example: "Peripheral sensory neuropathy: Decreased light touch and pinprick sensation in stocking-glove distribution to mid-feet and fingertips bilaterally. Vibration sense intact at ankles. Motor strength 5/5 throughout. DTRs 1+ at ankles (baseline 2+). Gait steady. Fine motor: Mild difficulty with rapid alternating movements."

   Skin Examination:

   • Hand-foot syndrome assessment
   • Rash (including immune-related)
   • Nail changes
   • Injection site reactions
   • Example: "Skin: No hand-foot syndrome. No rash. Mild nail ridging and discoloration on fingernails. No injection site reactions."

   Oral Cavity:

   • Mucositis grading
   • Thrush assessment
   • Hydration status
   • Example: "Oral mucosa: Grade 1 mucositis with mild erythema of buccal mucosa, no ulcerations. No thrush. Moist membranes."

5. System-Based Examination (Cancer-Specific):

   • Lymph Nodes: All accessible nodal basins
   • Abdomen: Hepatomegaly, masses, ascites
   • Lungs: Breath sounds, effusion signs
   • Extremities: Edema, DVT signs
   • Neurological: Focal deficits, mental status

6. Laboratory Results:

   Complete Blood Count (Critical for Treatment):

   • WBC with ANC (Absolute Neutrophil Count)
   • Hemoglobin and Hematocrit
   • Platelet count
   • Example: "CBC: WBC 4.2 (ANC 2,100), Hgb 11.2, Hct 33.8, Plt 156. Nadir labs from cycle 3 day 10: ANC 800, Hgb 10.1, Plt 98."

   Comprehensive Metabolic Panel:

   • Renal function (dosing adjustments)
   • Hepatic function (metabolism, metastatic disease)
   • Electrolytes

   Tumor Markers:

   • CEA for colorectal cancer
   • CA-125 for ovarian cancer
   • PSA for prostate cancer
   • CA 19-9 for pancreatic cancer
   • AFP, HCG for germ cell tumors
   • Example: "CEA: 2.8 ng/mL (baseline pre-surgery 45.2, post-surgery 3.1, prior cycle 3.0) - within normal limits, stable"

7. Imaging Results with RECIST Assessment:

   RECIST 1.1 Criteria (Response Evaluation Criteria in Solid Tumors):

   • Complete Response (CR): Disappearance of all target lesions
   • Partial Response (PR): >=30% decrease in sum of diameters of target lesions
   • Progressive Disease (PD): >=20% increase in sum of diameters OR new lesions
   • Stable Disease (SD): Neither sufficient shrinkage nor sufficient increase

   Document:

   • Target lesions with measurements
   • Non-target lesions
   • New lesions
   • Overall response
   • Example: "CT Chest/Abdomen/Pelvis (12/20/2025): No evidence of recurrent disease. Surgical site unremarkable. No lymphadenopathy. Liver, lungs clear. RECIST Assessment: Not applicable (adjuvant setting, no measurable disease)."

8. Pathology/Molecular Results:

   • Histopathology
   • Immunohistochemistry
   • Molecular markers (KRAS, BRAF, MSI, HER2, etc.)
   • Genomic profiling results
   • Example: "Pathology (surgical specimen): Moderately differentiated adenocarcinoma, pT3N2aM0, 4/18 lymph nodes positive. LVI present, PNI present. Margins negative (R0). IHC: MSS (MLH1+, MSH2+, MSH6+, PMS2+). Molecular: KRAS wild-type, BRAF wild-type."

Example Objective Section for Oncology

Assessment Section (A)

The oncology Assessment synthesizes clinical findings, documents staging, evaluates treatment response and toxicity, and informs treatment decisions.

Assessment Section (A) Components

1. Cancer Diagnosis with Complete Staging:

   • Primary diagnosis with ICD-10 code
   • TNM staging (clinical and/or pathologic)
   • AJCC stage and edition
   • Key prognostic factors
   • Example: "Sigmoid colon adenocarcinoma, pT3N2aM0, Stage IIIB (AJCC 8th edition). MSS, KRAS wild-type. High-risk features: N2 disease, LVI, PNI."

2. Treatment Status:

   • Current treatment regimen
   • Cycle number and day
   • Treatment intent (curative, adjuvant, neoadjuvant, palliative)
   • Example: "Currently receiving adjuvant FOLFOX chemotherapy, Cycle 4 of planned 12 cycles (6 months). Curative intent."

3. Treatment Response Assessment: For patients with measurable disease:

   • RECIST 1.1 category (CR, PR, SD, PD)
   • Tumor marker trends
   • Clinical response
   • Example: "RECIST: Partial response with 45% decrease in sum of target lesions. CEA decreased from 125 to 28. Clinical improvement in symptoms."

4. Toxicity Assessment Summary: Document all treatment-related toxicities with CTCAE grades:

   • List each toxicity with grade
   • Comparison to prior cycle
   • Impact on dose/schedule
   • Example:
     • "Peripheral neuropathy: Grade 2 (progressed from Grade 1) - limiting instrumental ADL"
     • "Fatigue: Grade 2 - stable from prior cycle"
     • "Nausea: Grade 1 - improved from Grade 2 with antiemetic adjustment"
     • "Myelosuppression: Nadir ANC 800 (Grade 3) - recovered"

5. Dose Modification Assessment:

   • Need for dose reduction
   • Need for treatment delay
   • Supportive care adjustments
   • Example: "Oxaliplatin dose reduction indicated per protocol for Grade 2 neuropathy. Recommend 25% dose reduction (from 85 to 65 mg/m2)."

6. Performance Status Trend:

   • Current ECOG with change from baseline
   • Functional implications
   • Example: "ECOG 1 (baseline 0). Decline attributable to treatment-related fatigue; no evidence of disease progression."

7. Supportive Care Assessment:

   • Pain control adequacy
   • Antiemetic efficacy
   • Growth factor needs
   • Nutritional status
   • Psychosocial needs

Cancer Staging Documentation Requirements

TNM Staging Components:

• T (Tumor): Size and extent of primary tumor
• N (Nodes): Regional lymph node involvement
• M (Metastasis): Distant metastasis

Prefixes:

• c: Clinical staging (pre-treatment imaging and exam)
• p: Pathologic staging (post-surgical)
• y: Post-neoadjuvant therapy
• r: Recurrent tumor

Document:

• Staging edition (e.g., AJCC 8th edition)
• Stage grouping (I, II, III, IV)
• Key histopathologic features
• Molecular/genomic markers

Example Assessment Section for Oncology

Plan Section (P)

The oncology Plan must comprehensively address treatment administration, dose modifications, supportive care, monitoring, and follow-up while maintaining compliance with protocols and guidelines.

Plan Section (P) Components

1. Chemotherapy/Immunotherapy Administration:

   • Regimen name and cycle/day
   • Individual drug doses (with dose modifications noted)
   • BSA-based calculations
   • Infusion schedule
   • Pre-medications
   • Example:
     • "FOLFOX Cycle 4 Day 1:"
     • "Oxaliplatin 127 mg (65 mg/m2 x 1.96 m2) - 25% dose reduction for Grade 2 neuropathy"
     • "Leucovorin 784 mg (400 mg/m2 x 1.96 m2)"
     • "5-FU bolus 784 mg (400 mg/m2 x 1.96 m2)"
     • "5-FU infusion 4,704 mg (2400 mg/m2 x 1.96 m2) over 46 hours"

2. Dose Modifications:

   • Specific modifications made
   • Rationale (toxicity grade, per protocol)
   • Reference to treatment protocol
   • Example: "Oxaliplatin dose reduced 25% (from 85 to 65 mg/m2) per FOLFOX protocol for Grade 2 peripheral neuropathy. 5-FU and leucovorin continued at full dose."

3. Supportive Care Medications:

   • Antiemetics (acute and delayed)
   • Growth factors (G-CSF if indicated)
   • Pain management
   • Anti-diarrheals
   • Neuropathy management
   • Example:
     • "Pre-medications: Ondansetron 8mg IV, Dexamethasone 12mg IV"
     • "Post-chemo: Ondansetron 8mg PO TID PRN x 3 days, then PRN"
     • "Pegfilgrastim 6mg SC on Day 2 (if indicated)"

4. Clinical Trial Documentation (if applicable):

   • Protocol number
   • Study drug administration
   • Protocol-specific assessments
   • Adverse event reporting
   • Example: "Patient enrolled in Protocol ABC-123. Study drug administered per protocol. Grade 2 neuropathy reported to sponsor per protocol requirements."

5. Laboratory Monitoring:

   • Labs ordered and timing
   • Specific parameters to follow
   • Thresholds for notification
   • Example:
     • "CBC with differential: Prior to each cycle"
     • "CMP: Prior to each cycle"
     • "Nadir labs: Day 10 of each cycle (CBC)"
     • "CEA: Every 3 cycles (with restaging)"

6. Imaging and Restaging:

   • Next imaging scheduled
   • Tumor marker schedule
   • Response assessment timing
   • Example: "CT Chest/Abdomen/Pelvis at completion of chemotherapy (after Cycle 12) for restaging. CEA to be checked with restaging labs."

7. Toxicity Management Plan:

   • Specific interventions for ongoing toxicities
   • Patient instructions
   • When to call/return
   • Example:
     • "Neuropathy: Avoid cold exposure, use gloves for cold items. Gabapentin 100mg TID may be initiated if symptoms worsen."
     • "Diarrhea: Loperamide 4mg initially, then 2mg after each loose stool (max 16mg/day). Call if >6 stools/day or fever."

8. Referrals and Consultations:

   • Multidisciplinary team involvement
   • Supportive services
   • Example:
     • "Nutrition: Referral to oncology dietitian for weight loss"
     • "Palliative care: Not indicated at this time"
     • "Survivorship: Will refer at completion of treatment"

9. Patient Education:

   • Treatment expectations
   • Side effect management
   • Emergency instructions
   • Example: "Reviewed signs/symptoms requiring immediate attention: fever >100.4F, severe diarrhea, uncontrolled nausea/vomiting, bleeding, new or worsening neurological symptoms."

10. Follow-Up:

    • Next treatment date
    • Monitoring appointments
    • Restaging schedule
    • Example:
      • "Cycle 4 Day 1: Today"
      • "Pump disconnect: Day 3 (home health or return to clinic)"
      • "Nadir labs: Day 10"
      • "Cycle 5 Day 1: January 10, 2026"

Example Plan Section for Oncology

AI-Assisted Documentation for Oncology

As of 2025, 66% of healthcare providers utilize AI tools in their practice. AI scribes and ambient clinical intelligence can significantly reduce documentation burden for oncologists while maintaining comprehensive cancer care records.

How AI Can Help with Oncology Documentation

• Treatment tracking: Accurately captures chemotherapy cycles, dates, and regimen changes
• Symptom documentation: Records patient-reported symptoms with severity descriptions
• Medication reconciliation: Documents complex supportive care regimens
• Template population: Generates structured notes following oncology documentation standards
• Follow-up scheduling: Captures treatment schedules and monitoring plans

Oncology-Specific AI Considerations

What AI captures well:

• Patient-reported symptoms and treatment tolerance
• Performance status descriptions
• Medication lists including supportive care
• Treatment schedule discussions
• Patient education topics covered
• Follow-up plans

What requires careful review:

• CTCAE grading: Verify AI-assigned toxicity grades match clinical assessment
• Dose calculations: Confirm BSA-based dosing and dose modifications are accurate
• Staging information: Verify TNM staging and stage grouping accuracy
• Tumor marker values: Confirm exact values and trends
• RECIST assessments: Verify response categorization matches imaging reports
• Protocol-specific documentation: Ensure clinical trial requirements are met
• Drug doses and modifications: Double-check all chemotherapy doses

Tips for Using AI with Oncology Documentation

1. State CTCAE grades explicitly: "The patient has Grade 2 peripheral neuropathy, limiting instrumental ADLs"
2. Verbalize dose modifications: "Due to Grade 2 neuropathy, we are reducing oxaliplatin by 25 percent, from 85 to 65 milligrams per meter squared"
3. Dictate performance status clearly: "ECOG performance status is 1, unchanged from last visit"
4. Specify tumor marker values: "CEA is 2.8, which is normalized and stable from the prior value of 3.0"
5. State treatment intent: "This is adjuvant chemotherapy with curative intent"
6. Review staging carefully: Verify all TNM components and stage grouping

For more details, see our complete AI-Assisted Documentation Guide.

Telehealth Oncology Documentation

Virtual oncology care has expanded significantly for symptom monitoring, treatment tolerance assessments, and survivorship follow-up. Per CMS 2026 guidelines, telehealth services continue with specific documentation requirements.

Telehealth-Appropriate Oncology Services

1. Treatment Tolerance Monitoring:

   • Between-cycle symptom assessment
   • Toxicity monitoring and grading
   • Medication adjustments
   • Supportive care optimization

2. Survivorship Follow-Up:

   • Post-treatment surveillance
   • Late effects monitoring
   • Quality of life assessment
   • Psychosocial support

3. Symptom Management:

   • Pain assessment and management
   • Nausea/emesis management
   • Fatigue counseling
   • Depression/anxiety screening

4. Results Review:

   • Laboratory result review
   • Tumor marker trending
   • Imaging review and discussion
   • Pathology result discussion

Telehealth Oncology Documentation Requirements

For virtual oncology visits, document:

1. Visit logistics:

   • Platform used (HIPAA-compliant)
   • Patient and provider locations
   • Consent for telehealth services
   • Audio/video quality

2. Modified physical examination:

   • Visual assessment of performance status
   • Patient self-reported findings (weight, temperature if available)
   • Visible examination (skin, port site if visible, visible lymphadenopathy)
   • Limitations clearly documented

3. Toxicity assessment via telehealth:

   • Patient-reported symptoms with grades
   • Functional status assessment via observation and report
   • Clear documentation of what could not be assessed

4. Treatment eligibility assessment:

   • Review of recent laboratory values
   • Performance status assessment
   • Determination if in-person visit needed before treatment

Example Telehealth Oncology Documentation

Survivorship Telehealth Visit

For complete telehealth documentation guidance, see our Telehealth SOAP Notes Guide.

Specialty Documentation Templates

Chemotherapy Treatment Visit Template

Toxicity Assessment Template

Free Oncology SOAP Note Template

Related Resources

• Emergency Medicine SOAP Notes
• Telehealth SOAP Notes Guide
• AI-Assisted Documentation Guide
• Free SOAP Note Templates