Urologist Template

Inpatient Urology Consult

A professional Urologist template for healthcare professionals.

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Specialty

Urologist

Used

40 times

Type

Note

Last edited

6/19/2025

Created by

David Canes

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About this template

The Inpatient Urology Consult template is designed for urologists to document comprehensive evaluations of patients referred for urological issues. This template includes sections for patient information, medical history, physical examination findings, and a detailed assessment and plan. It is particularly useful for documenting cases involving recurrent urinary tract infections, hematuria, or other urological conditions. The template ensures thorough documentation, aiding in effective communication with referring physicians and facilitating continuity of care. This structured format is optimized for use with AI medical scribe tools like Heidi, enhancing efficiency and accuracy in clinical documentation.

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PATIENT INFORMATION: - Name: John Doe - Date of Birth: 15 March 1965 - Medical Record Number: 123456789 - Date of Consultation: 1 November 2024 REFERRING PHYSICIAN: - Name: Dr. Emily Smith - Contact Information: emily.smith@hospital.org REASON FOR CONSULTATION: - Evaluation of recurrent urinary tract infections and hematuria. HISTORY OF PRESENT ILLNESS: - The patient, a 59-year-old male, presents with a history of recurrent urinary tract infections over the past six months, accompanied by episodes of hematuria. He reports dysuria and increased urinary frequency. No fever or flank pain noted. Previous treatments with antibiotics have provided temporary relief. PAST MEDICAL HISTORY: - Hypertension, Type 2 Diabetes Mellitus, Benign Prostatic Hyperplasia. PAST SURGICAL HISTORY: - Appendectomy in 1985, Transurethral Resection of the Prostate (TURP) in 2018. MEDICATIONS: - Lisinopril 10 mg daily, Metformin 500 mg twice daily, Tamsulosin 0.4 mg daily. ALLERGIES: - Penicillin (rash) SOCIAL HISTORY: - Smokes 10 cigarettes per day, occasional alcohol use, retired accountant. FAMILY HISTORY: - Father had prostate cancer. PHYSICAL EXAMINATION: - General: Alert, oriented, vital signs stable. - Abdomen: Soft, non-tender, no organomegaly. - Genitourinary: Mild tenderness over the bladder, no palpable masses. - Other: No peripheral edema. LABS AND IMAGING SYNTHESIS: - Urinalysis shows pyuria and hematuria. Ultrasound of the kidneys and bladder reveals no stones or masses. ASSESSMENT: - Recurrent urinary tract infections, likely secondary to benign prostatic hyperplasia. ICD-10 Codes: N39.0, N40.1 PLAN: - Initiate a course of ciprofloxacin for 7 days. Schedule a cystoscopy to evaluate for any underlying bladder pathology. Continue current medications for hypertension and diabetes. FOLLOWUP: - Follow-up in two weeks to review cystoscopy results and assess response to treatment. CONSULTANT UROLOGIST: - Name: Dr. Thomas Smith - Date: 11/01/2024 “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.”