Urologist Template

Prostatectomy Followup

A professional Urologist template for healthcare professionals.

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Specialty

Urologist

Used

97 times

Type

Note

Last edited

9/18/2025

Created by

David Canes

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About this template

Need a quick and comprehensive way to document a urology patient's prostatectomy follow-up? This Prostatectomy Followup template is designed specifically for urologists. It helps streamline the note-taking process by focusing on key aspects like cancer history, recovery milestones, current symptoms, and treatment plans. With Heidi, this template can be automatically populated from your patient's visit transcript, saving you time and ensuring all critical information is captured accurately for your medical documentation needs.

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SHORT SUMMARY: Mr. Smith, a 68-year-old man, presents for a follow-up after prostatectomy. He reports improved urinary continence and is managing erectile dysfunction with medication. CHIEF COMPLAINT: Mr. Smith is a 68-year-old man, presents to the office today to follow-up after prostatectomy on 06/15/2024 for T2aN0M0, Gleason 3+4=7, margin negative. He is 4 months postop. PROSTATE CANCER HISTORY: Mr. Smith was diagnosed with localized prostate cancer in March 2024 after an elevated PSA of 6.2 ng/mL. A subsequent MRI showed a suspicious lesion in the right peripheral zone. A prostate biopsy confirmed adenocarcinoma, Gleason 3+4=7. He underwent a robotic-assisted radical prostatectomy on June 15, 2024, performed by Dr. Thomas Kelly. Pathology revealed T2aN0M0, Gleason 3+4=7, with negative margins. RECOVERY MILESTONES: - Urinary continence: Achieved continence with one pad per day as of September 2024. - Urinary stream: Good urinary stream, no hesitancy or straining, as of September 2024. - Erectile function: Preop function was good. Postop function is improved with Tadalafil 5mg daily. HPI TODAY 11/01/2024: - 4 months since prostatectomy. - Reports improved urinary continence and erectile function with medication. - No new urinary symptoms. - PSA level is 0.01 ng/mL, drawn on October 25, 2024. PMH, PSH, MEDS, ALLERGIES, SH, and FH: - PMH: Hypertension, well controlled with medication. - MEDS: Tadalafil 5mg daily, Amlodipine 5mg daily. - ALLERGIES: NKDA. ASSESSMENT AND PLAN: Mr. Smith, a 68-year-old man, is 4 months post-radical prostatectomy for localized prostate cancer. He is doing well with good urinary control and improved erectile function. 1. Prostate Cancer (Prostate cancer, C61) - Assessment: PSA is undetectable. No evidence of recurrence. - Plan: Continue PSA monitoring every 6 months. - Counseling: Discussed the importance of continued follow-up and monitoring for any signs of recurrence. 2. Stress incontinence (and ICD-10 code) - Assessment: Improved continence with one pad per day. - Plan: Continue pelvic floor exercises. - Counseling: Reviewed pelvic floor exercises and discussed strategies for managing occasional leakage. 3. Erectile dysfunction (and ICD-10 code) - Assessment: Improved erectile function with Tadalafil. - Plan: Continue Tadalafil 5mg daily. - Counseling: Discussed the importance of medication adherence and potential side effects. ORDERS: PSA blood test in 6 months. FOLLOW UP: Follow up in 6 months for PSA and clinical assessment.