woman in white scrub suit holding gray laptop computer

AI Scribe for Oncology

Transcribe Health drafts your consult, treatment-visit, and surveillance notes while you talk to the patient, so the staging, regimen, and toxicity detail is on the page before you move to the next chair.

Start Free Trial View All Specialties

Photo: National Cancer Institute / Unsplash

Oncology documentation, from new diagnosis to surveillance

A new-patient consult in oncology is one of the longest notes in medicine. You are pulling together the biopsy, the stage, the imaging, the molecular panel, the comorbidities, and a treatment plan the patient has to understand and agree to, often in a single emotionally heavy visit. All of it has to land in the note accurately, because every visit after this one refers back to it.

Treatment visits are shorter but relentless. Cycle number, labs and counts, the toxicity review, the ECOG score, whether you are dosing at full strength or reducing, whether therapy proceeds or holds. A patient on FOLFOX or on a checkpoint inhibitor generates the same structured review every two or three weeks, and each one has to be its own defensible note.

Then there is surveillance. The patient is off active treatment, and the visit turns on the scan, the tumor markers, and the exam, with the question of recurrence sitting underneath. Transcribe Health listens to whichever of these you are in and drafts the note that fits it: staging and plan for a consult, counts and toxicity for a treatment visit, the response read for surveillance. You review it and sign. Nothing is filed without you.

Documentation Challenges in Oncology

1
Recording stage at diagnosis with the correct TNM breakdown, histology, receptor and molecular markers, and keeping it consistent every time it is referenced later
2
Documenting chemotherapy and immunotherapy by regimen, cycle number, dose, dose reductions, and the reason behind each change, so the treatment history reads cleanly months down the line
3
Capturing a full toxicity review with CTCAE-style grading, the ECOG performance status, and the response assessment (RECIST, imaging, tumor markers) that justify continuing, holding, or switching therapy

How Transcribe Health Helps Oncology

Treatment History That Holds Together

Keeps the regimen name, cycle number, and dose changes in the note so the record still makes sense when you or a covering colleague read it three cycles later.

Toxicity and Performance Status

Records the side effects the patient reports, the grade you assign, and the ECOG or Karnofsky score, in the format your treatment decisions rest on.

Staging and Response Assessment

Writes up the stage, histology, and molecular markers at diagnosis, and the response read (RECIST, scan findings, tumor markers) at each reassessment, without you retyping the numbers.

An oncology note, captured in real time

An abridged treatment visit for a patient on adjuvant chemotherapy, drafted the way you would see it before signing.

Treatment visit · Stage III colon cancer, FOLFOX cycle 4 of 12

Subjective

58-year-old woman here for cycle 4 of adjuvant FOLFOX following right hemicolectomy for stage III (pT3 N1 M0) colon adenocarcinoma. Reports grade 1 cold-induced peripheral neuropathy in the fingertips, no worse than the prior cycle, no difficulty with buttons or handling objects. Grade 1 fatigue for two to three days after infusion, then back to baseline. No diarrhea, no mucositis, no fevers. Eating well, weight stable. ECOG performance status 1.

Objective

BP 124/78, HR 72, afebrile. Well appearing, no pallor. Abdomen soft, incision well healed, no organomegaly. Port site clean and dry, no erythema. Labs today: WBC 4.2, ANC 2100, hemoglobin 11.4, platelets 165. Bilirubin, AST, and ALT within normal limits. Creatinine 0.8. Counts adequate to proceed.

Assessment

1) Stage III (pT3 N1 M0) colon adenocarcinoma, status post right hemicolectomy, on adjuvant FOLFOX, cycle 4 of 12. Tolerating treatment well. 2) Oxaliplatin-related peripheral sensory neuropathy, grade 1, stable. 3) Chemotherapy-related fatigue, grade 1.

Plan

Proceed with FOLFOX cycle 4 today at full dose: oxaliplatin 85 mg/m2, leucovorin 400 mg/m2, 5-FU 400 mg/m2 bolus then 2400 mg/m2 over 46 hours. Continue home antiemetics. Reviewed cold-avoidance measures for the neuropathy; will monitor grade each cycle and reduce oxaliplatin if it reaches grade 2. CBC with differential and CMP before the next cycle. Return in two weeks for cycle 5. Patient understands the plan and agrees to continue.

Illustrative example. Not a real patient encounter.

Built for oncology coding and your EMR

Notes capture the counts you reviewed, the toxicity grade, the performance status, and the decision to proceed or hold, which is the detail that backs your E/M level and the medical necessity of each drug administration. That is what auditors look for, and the first thing to slip when the infusion suite is full.

CPT

99204 / 99205New-patient consult, moderate to high complexity
99214 / 99215Established-patient follow-up, moderate to high complexity
96413Chemotherapy IV infusion, up to 1 hour, single drug
96415Chemotherapy IV infusion, each additional hour
96417Chemotherapy IV infusion, each additional sequential drug
96360IV hydration infusion, initial 31 minutes to 1 hour

ICD-10

C50.911Malignant neoplasm of unspecified site of right female breast
C18.9Malignant neoplasm of colon, unspecified
Z51.11Encounter for antineoplastic chemotherapy
D63.0Anemia in neoplastic disease
R50.9Fever, unspecified

Fits the workflow you already have

Drafts drop into the major EMRs oncology practices run on: Epic (including Beacon oncology workflows), Oracle Health (Cerner), and athenahealth, alongside the OncoEMR and iKnowMed systems many community groups use. You get whatever note type you are working in, a new-patient consult, a treatment visit, or a surveillance follow-up. It writes up the staging, regimen, and toxicity review you dictate. It does not build your chemotherapy orders or replace the treatment plan in your ordering system; you make the call and it records it.

Oncology AI scribe questions

Does it understand oncology terminology, regimens, and drug names?

Yes. It captures regimen names like FOLFOX, R-CHOP, and carboplatin/paclitaxel, individual agents and their doses, and values like ECOG performance status, ANC, and TNM stage, with correct spelling rather than phonetic guesses.

Can it keep the cycle number and dose changes straight across visits?

It records the cycle number, the dose given, and any reduction along with the reason you state, so the treatment history in the note stays accurate. It documents what you say in the visit; it is not a substitute for the chemotherapy order in your EMR.

Will it help with coding and audit defensibility?

It surfaces the toxicity grade, performance status, counts reviewed, and the decision to proceed or hold that support your E/M level and the medical necessity of each infusion code. In practice that reduces both under-coding and audit exposure.

How is patient information protected?

All data is encrypted in transit and at rest, handled under a Business Associate Agreement available on every plan, and covered by HIPAA for US practices and PHIPA and PIPEDA for Canadian practices.

Does it connect to our EMR and ordering system?

Structured notes drop into major EMRs including Epic, Oracle Health, athenahealth, OncoEMR, and iKnowMed. It documents the staging, regimen, and toxicity review you describe; it does not create or modify chemotherapy orders in your ordering system.

HIPAA Compliant

Ready to Transform Your Documentation?

Join thousands of healthcare providers who save hours every day with AI-powered medical transcription.

Start Free Trial