SHORT SUMMARY:
"This is a 65-year-old man who presents for follow-up regarding his renal cyst. The cyst has shown no significant changes, and the patient remains asymptomatic."
**CHIEF COMPLAINT:**
Patient presents to the office today to discuss:
1. Follow-up on renal cyst
2. Review of recent imaging results
3. Discussion of any new symptoms
**PAST UROLOGICAL HISTORY:**
"Mr. Smith is a 65-year-old man with a history of a renal cyst first identified two years ago. Initial ultrasound showed a Bosniak IIF cyst measuring 3.5 cm. Follow-up CT scans have shown stable size and characteristics. He underwent a cystoscopy last year, which was unremarkable. Mr. Smith is a retired engineer who enjoys hiking and photography. He has been under the care of Dr. Thomas Kelly."
**RENAL CYST HISTORY:**
- Bosniak IIF classification, CT scan on 15 March 2023, cyst size 3.5 cm, stable characteristics.
- Prior plan: Continue monitoring with annual imaging and follow-up visits.
**HPI TODAY [11/01/2024]:**
- No new changes related to the renal cyst. The patient reports no pain or hematuria.
- Recent ultrasound on 1 October 2024 at City Hospital shows no change in cyst size or features. I personally reviewed and independently interpreted the scan and concur with findings.
**PMH, PSH, MEDS, ALLERGIES, SH, and FH:**
- No changes in PMH, PSH, MEDS, ALLERGIES, SH, and FH since last visit.
**PHYSICAL EXAMINATION:**
Constitutional: Alert and oriented, no acute distress.
Psychiatric: Mood and affect appropriate, cooperative behavior.
GU exam: Not performed today.
**ASSESSMENT AND PLAN:**
65-year-old man with a stable Bosniak IIF renal cyst.
1. Renal cyst (N28.1)
- Assessment: Stable Bosniak IIF cyst with no new symptoms.
- Plan: Continue annual imaging and follow-up. Next ultrasound in one year.
- Counseling: Discussed the benign nature of the cyst and the importance of regular monitoring.
**ORDERS:**
No orders.
**FOLLOW UP:**
Follow-up in one year with repeat ultrasound.
SHORT SUMMARY:
"This is a 65-year-old man who presents for follow-up regarding his renal cyst. The cyst has shown no significant changes, and the patient remains asymptomatic."
“Consent for the use of AI-assisted tools for documentation was obtained from the patient and all other participants in the visit prior to this encounter. All questions were answered. Patient understands that they may decline the use of AI-assisted tools.”
(write this as a Urologist, using moderate amount of details, and inserting quotes from the patient where appropriate)
SHORT SUMMARY:
["This is a [age] [man/woman]" ...two sentence summary of this visit including the most relevant aspects only (exactly what me and my team would need to read as a memory jog in the future; use "man" and "woman" instead of "male" or "female")]
**CHIEF COMPLAINT:**
[[Patient presents to the office today to discuss:
1. [Medical issue 1]
2. [Medical issue 2]
3. [Medical issue 3]]]
**PAST UROLOGICAL HISTORY:**
"Mr/Mrs Lname is a [age] {man/woman]"... [Summarize past visit timeline in no more than 5-6 sentences (paragraph format). Include labs, pathology results, imaging, and procedures. Include relevant data that a urologist would want to refer back to in order to quickly reorient to the patient. Please include patient occupation and hobbies if known. Please include names of involved physicians and APPs if known. (do NOT include things relating to today's visit, this part should be historical, excluding today, which goes in the HPI TODAY section below; use "man" and "woman" instead of "male" or "female")]]
**RENAL CYST HISTORY:**
- [Bulleted list of Bosniak classification, with date and type of scan, size of cyst and any other features that seem important]
- [Prior plan: (description of what I said about the cyst and what we plan to do)]
**HPI TODAY [Date of current consultation in US format]:**
- [Description new changes related to the urologic conditions for which the patient is being followed (in particular new information since the last visit).]
- [Description of current symptoms or lack thereof (otherwise omit).]
- [Relevant imaging results and their interpretation. (only if available and only if some time of imaging scan was done, otherwise omit. If available, always include date and location of scan, and the phrase "I personally reviewed and independently interpreted the scan and concur with findings.)]
- [Relevant test results and their interpretation. (only if available, otherwise omit)]
- [AUA Symptom score if performed (otherwise omit)]
- [PVR if performed (only if done, otherwise omit)]
- [PSA density (if recent PSA is available and prostate gland size is known, calculate PSAD by dividing PSA/gland size and report the result, otherwise omit)]
**[PMH, PSH, MEDS, ALLERGIES, SH, and FH:**
[Information reviewed with patient and in EMR, with changes made where appropriate.]
- [Any updated information related to PMH, PSH, MEDS, ALLERGIES, SH, and FH in bulleted format (only if mentioned, otherwise omit)] (entire section can be omitted if nothing relevant this visit)]
**[PHYSICAL EXAMINATION:**
[Constitutional: General appearance and state of distress. Level of consciousness.]
[Psychiatric: Mood and affect. Behavior. Judgment and thought content.]
[GU exam if performed]. (entire section omitted if no physical exam)]
**ASSESSMENT AND PLAN:**
[Patient's age and a brief 1-3 sentence summary of their condition (use "man" and "woman" instead of "male" or "female")]
(Note: if I ever start, stop, or continue a medication, please include under the appropriate Plan section below the statement "Medication regimen reviewed, including risks, benefits, adherence, and need for adjustments. Decision made to [continue/adjust/discontinue/initiate] [medication name, and dose if known] based on patient's condition and response to treatment.")
1. [Medical issue 1 (condition name and ICD-10 code, urology related issues only)]
- [Assessment: Current assessment of the condition.]
- [Plan: Proposed plan for management or follow-up.]
- [Counseling: Description of the condition, natural history, or similar, (include only if discussed otherwise omit).]
2. [Medical issue 2 (condition name and ICD-10 code, urology related issues only)]
- [Assessment: Current assessment of the condition.]
- [Plan: Proposed plan for management or follow-up.]
- [Counseling: Description of the condition, natural history, or similar, (include only if discussed otherwise omit).]
3. [Medical issue 3, 4, 5, etc (condition name and ICD-10 code, urology related issues only)]
- [Assessment: Current assessment of the condition.]
- [Plan: Proposed plan for management or follow-up.]
- [Counseling: Description of the condition, natural history, or similar, (include only if discussed otherwise omit).]
**ORDERS:**
[List orders for labs or medications. (only if orders mentioned otherwise "No orders.")]
**FOLLOW UP:**
[Follow-up plan time frame including future tests ordered (only if mentioned otherwise omit)].
SHORT SUMMARY:
["This is a [age] [man/woman]" ...two sentence summary of this visit including the most relevant aspects only (exactly what me and my team would need to read as a memory jog in the future; use "man" and "woman" instead of "male" or "female")]
“Consent for the use of AI-assisted tools for documentation was obtained from the patient and all other participants in the visit prior to this encounter. All questions were answered. Patient understands that they may decline the use of AI-assisted tools.”
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note.)
