CHIEF COMPLAINT:
Patient presents to the office today for cystoscopy and left stent removal.
PRIOR HISTORY:
Patient is a 68-year-old male with a history of gross hematuria and left flank pain. He underwent a left ureteroscopy with stent placement on 10/15/2024 for a 1.5 cm upper ureteral stone. Pathology from the stone was consistent with calcium oxalate. The referring physician was Dr. Emily Carter.
KEY INFORMATION:
- Prior procedure: Left ureteroscopy with stent placement for a 1.5 cm upper ureteral stone.
PMH, PSH, MEDS, ALLERGIES, SH, and FH:
Information reviewed with patient and in EMR, with changes made where appropriate.
- Updated PMH: Hypertension, Hyperlipidemia, Benign Prostatic Hyperplasia.
- Updated PSH: Appendectomy at age 10.
- Updated medications: Amlodipine 5mg daily, Atorvastatin 20mg daily, Tamsulosin 0.4mg daily.
- Updated allergies: NKDA.
- Updated social history: Non-smoker, occasional alcohol use.
- Updated family history: Father with prostate cancer.
OFFICE CYSTOSCOPY AND STENT REMOVAL:
Indications: Left ureteral stent removal following ureteroscopy for a left upper ureteral stone.
After proper informed consent was obtained, and procedural time out performed, the flexible cystoscope was inserted per urethra into the bladder. The anterior urethra and prostate were unremarkable. The distal coil of the left ureteral stent was visualised, grasped, and removed intact without difficulty.
ANTIBIOTICS:
Ciprofloxacin 500mg was given x 1.
ASSESSMENT AND PLAN:
Patient is a 68-year-old male who underwent successful left ureteral stent removal today. He is doing well post-procedure.
1. Left Ureteral Stone (ICD-10 code: N20.1)
- Assessment: Stone successfully removed with prior ureteroscopy. No evidence of residual stone.
- Plan: Patient instructed to increase fluid intake. Follow-up in 2 weeks.
- Counseling: Discussed the importance of hydration to prevent future stone formation.
2. Benign Prostatic Hyperplasia (ICD-10 code: N40.0)
- Assessment: Stable on Tamsulosin.
- Plan: Continue Tamsulosin 0.4mg daily.
- Counseling: Discussed the importance of medication adherence.
ORDERS:
Ciprofloxacin 500mg x 3 days.
FOLLOW UP:
Follow up in 2 weeks for a routine check-up.
SHORT SUMMARY:
Patient underwent successful left ureteral stent removal today. He is doing well and will follow up in two weeks.
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.
CHIEF COMPLAINT:
[Patient presents to the office today for cystoscopy and left/right stent removal] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
PRIOR HISTORY:
[Summarise urologic history as it relates to the current cystoscopy procedure in no more than 5–6 sentences. Include relevant labs, pathology results, imaging, cytology results, and procedures with dates. Include referring physician name and referring urologist name if known. Include only data a urologist would want to refer back to for quick orientation.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
KEY INFORMATION:
- Prior procedure: [Reason the stent was placed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
PMH, PSH, MEDS, ALLERGIES, SH, and FH:
[Information reviewed with patient and in EMR, with changes made where appropriate.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Updated PMH] (Only include if explicitly mentioned; otherwise omit completely.)
- [Updated PSH] (Only include if explicitly mentioned; otherwise omit completely.)
- [Updated medications] (Only include if explicitly mentioned; otherwise omit completely.)
- [Updated allergies] (Only include if explicitly mentioned; otherwise omit completely.)
- [Updated social history] (Only include if explicitly mentioned; otherwise omit completely.)
- [Updated family history] (Only include if explicitly mentioned; otherwise omit completely.)
OFFICE CYSTOSCOPY AND STENT REMOVAL:
Indications: [Indication for procedure, typically related to why the stent was placed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
After proper informed consent was obtained, and procedural time out performed, the flexible cystoscope was inserted per urethra into the bladder. (In males: add any relevant positive urethral or prostatic findings mentioned; if none, state “The anterior urethra and prostate were unremarkable.” In females: add any relevant urethral findings mentioned; if none, omit.) The distal coil of the [left/right] ureteral stent was visualised, grasped, and removed intact without difficulty. (If any additional positive findings were mentioned, incorporate them into the procedure description and adjust wording accordingly.)
ANTIBIOTICS:
[Medication name] was given x 1. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
ASSESSMENT AND PLAN:
[Patient’s age and a brief 1–3 sentence summary of their urologic situation.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
1. [Medical issue 1 (condition name and ICD-10 code)] (Only include if explicitly mentioned; otherwise omit completely.)
- Assessment: [Current assessment of the condition.] (Only include if explicitly mentioned; otherwise omit completely.)
- Plan: [Proposed plan for management or follow-up.] (Only include if explicitly mentioned; otherwise omit completely.)
- Counseling: [Description of the condition, natural history, or similar.] (Only include if explicitly mentioned; otherwise omit completely.)
2. [Medical issue 2 (condition name and ICD-10 code)] (Only include if explicitly mentioned; otherwise omit completely.)
- Assessment: [Current assessment of the condition.] (Only include if explicitly mentioned; otherwise omit completely.)
- Plan: [Proposed plan for management or follow-up.] (Only include if explicitly mentioned; otherwise omit completely.)
- Counseling: [Description of the condition, natural history, or similar.] (Only include if explicitly mentioned; otherwise omit completely.)
3. [Medical issue 3, 4, 5 etc. (condition name and ICD-10 code)] (Only include if explicitly mentioned; otherwise omit completely.)
- Assessment: [Current assessment of the condition.] (Only include if explicitly mentioned; otherwise omit completely.)
- Plan: [Proposed plan for management or follow-up.] (Only include if explicitly mentioned; otherwise omit completely.)
- Counseling: [Description of the condition, natural history, or similar.] (Only include if explicitly mentioned; otherwise omit completely.)
ORDERS:
[List orders for labs or medications] (Only include if explicitly mentioned; otherwise state “No orders.”)
FOLLOW UP:
[Follow-up timeframe and any future tests ordered] (Only include if explicitly mentioned; otherwise omit completely.)
SHORT SUMMARY:
[Two-sentence summary of the patient and this visit, focusing on the most relevant aspects.] (Only include if explicitly mentioned; otherwise omit completely.)
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 included in your note. If any information related to a placeholder has not been explicitly mentioned, omit the placeholder completely.)
