As a urologist, precise and detailed clinical documentation is essential, particularly when handling kidney stone follow-ups. Here, we explore how to correctly write and format patient documentation using a structured approach, often represented by the SOAP (Subjective, Objective, Assessment, Plan) note format.

Subjective: History of Present Illness (HPI)

The HPI section should detail the patient's current symptoms and relevant history. For example:

Current imaging demonstrates a stone burden with a 6mm stone located in the left renal pelvis, measuring 1200 Hounsfield Units with a skin to stone distance of 10cm. The patient reports intermittent left flank pain and occasional urinary urgency. No blood in urine has been noted.

Objective: Past Stone and Medical History

This section includes the patient's previous medical encounters and conditions that may impact their current health:

• Past Stone History: Calcium oxalate stone; underwent lithotripsy in 2019; CT scan in 2019 showed a 5mm stone in the left kidney.

• Past Medical History: Hypertension, Hyperlipidemia.

Assessment and Plan

In this section, provide a clear analysis of the patient's condition and your plan for treatment:

The patient has a 6mm stone in the left renal pelvis with symptoms of flank pain and urinary urgency. Imaging confirms the stone parameters. Surgical options include ureteroscopy or shock wave lithotripsy.

Instructions for Stone Prevention

This part should contain advice for the patient to prevent further stone formation:

I suggested copious hydration, avoiding excessive animal protein, and limiting salt, colas, and cheese.

In the fast-paced world of urology, maintaining high-quality documentation can be time-consuming. AI medical scribes like Notis AI Medical Scribe offer a revolutionary way to streamline this process, ensuring accuracy and efficiency.

Notis AI Medical Scribe is designed to reduce the time healthcare professionals spend on documentation significantly. It leverages voice-to-text technology to transcribe patient interactions and generate structured SOAP notes, helping clinicians save up to 2 hours per day on administrative tasks.

Benefits of Using Notis AI for Urologists

The integration of Notis into a urologist's practice can transform the documentation process:

Time Efficiency: By cutting down patient documentation time by 80%, urologists can focus more on patient care, enhancing productivity and reducing burnout.

Ease of Use: Operating directly through WhatsApp, Notis eliminates the need for additional software, ensuring a seamless transition without the need to learn new interfaces.

High Accuracy: With a 99% accuracy rate in transcribing medical notes, Notis ensures that the documentation is precise and reliable.

Comprehensive Documentation: Notis converts patient consultations into structured SOAP notes instantly, allowing for efficient patient charting and retrieval.

Utilizing AI medical scribe technology like Notis can significantly improve the workflow for urologists, allowing them to dedicate more time to patient care while ensuring that documentation remains accurate and comprehensive.