Office Cysto (not bladder ca)

CHIEF COMPLAINT: [reason for cystoscopy] (Insert reason the patient is presenting today for cystoscopy. Use exact phrasing if provided in the transcript. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) PRIOR HISTORY: [urologic history summary] (Summarise urologic history as it relates to the current cystoscopy procedure in no more than 5–6 sentences. Include lab results, imaging, cytology, pathology, previous procedures with dates, referring physician and/or urologist names, and any other key data relevant to the current assessment. Write in paragraph form. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) KEY INFORMATION: - Diagnosis: [primary urologic diagnosis] (Insert the diagnosis prompting the need for cystoscopy such as microhematuria or gross hematuria. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) - Imaging history: [imaging history summary] (Insert a bulleted list of prior imaging scans, specifying the month/year and brief findings. If not known or not relevant, use “Not known” or “Not relevant.” Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) PMH, PSH, MEDS, ALLERGIES, SH, and FH: [review summary statement] (Write a sentence such as “Information reviewed with patient and in EMR, with changes made where appropriate.” Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) - [updated history items] (If applicable, include any new or updated information related to past medical history, surgical history, medications, allergies, social history, or family history. Present in bullet points. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) OFFICE CYSTOSCOPY: Indications: [indication for cystoscopy] (Insert the reason for the cystoscopy such as microscopic hematuria, gross hematuria, or another specified indication. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) "After proper informed consent was obtained, and procedural time out, the flexible cystoscope was inserted per urethra into the bladder. (In males: add any findings in the urethra, or if no findings, include 'The anterior urethra and prostate were unremarkable.' In females: include any relevant urethral findings.) The bladder was examined systematically, including scope retroflexion. Ureteral orifices were normal in size, number and location effluxing clear urine. All visible mucosa was without tumors, stones, or foreign bodies. (If any abnormal findings were mentioned, edit this paragraph to include the details and modify surrounding text accordingly.)" (Only include this entire OFFICE CYSTOSCOPY section if cystoscopy was explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) ASSESSMENT AND PLAN: [urologic summary] (Insert the patient’s age and a brief 1–3 sentence summary of their overall urologic status. Write in full sentences. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) 1. [medical issue 1 – condition and ICD-10] (Insert the name of the condition and ICD-10 code. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) - Assessment: [condition assessment] (Insert a brief clinical assessment of the current status of the condition. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) - Plan: [management plan] (Insert the proposed plan for investigation, treatment, or follow-up. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) - Counseling: [counseling discussion] (Include only if counseling or explanation of the condition, natural history, or management options was discussed. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) 2. [medical issue 2 – condition and ICD-10] - Assessment: [condition assessment] - Plan: [management plan] - Counseling: [counseling discussion] 3. [medical issue 3 – condition and ICD-10] - Assessment: [condition assessment] - Plan: [management plan] - Counseling: [counseling discussion] ORDERS: [lab and medication orders] (Insert orders for labs, imaging or prescriptions. If no orders are mentioned, write “No orders.” Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) FOLLOW UP: [follow-up plan] (Insert planned follow-up time frame, testing or imaging ordered for future visits. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) (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 in the transcript, contextual notes or clinical note, you must not state that the information has not been explicitly mentioned in your output, just leave the relevant placeholder or section out entirely. Use as many lines, paragraphs or bullet points as needed to capture all the relevant information from the transcript.) “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.”