Clinical documentation is a critical component of patient care, particularly in urology, where detailed tracking of conditions like prostate cancer is essential. The following example illustrates how to effectively document a patient's follow-up visit using a structured template, ensuring clarity and comprehensiveness.

Chief Complaint

This section states the reason for the patient's visit. For instance, "Patient presents to the office today to follow-up on prostate cancer on active surveillance, diagnosed in 2018 as T1c, Gleason 6 (3+3)." This succinctly captures the purpose of the visit.

Prostate Cancer History

Documenting the patient's cancer history involves noting initial diagnosis details, biopsy results, PSA levels, and any ongoing surveillance. Example: "The patient was diagnosed in 2018 with a PSA of 4.5 ng/mL; biopsy revealed Gleason 6 (3+3) in 2 of 12 cores. Active surveillance has been ongoing since diagnosis."

Key Information

Consolidate critical data points such as biopsy and MRI history, PSA density (PSAD), and any genomic information if available. Example: "PSAD: 0.125; MRI History: March 2018 - 40 cc, PIRADS 2, no significant lesions."

HPI (History of Present Illness)

Detail any changes or symptoms since the last visit. Example: "No new changes related to prostate cancer since the last visit; no current symptoms."

Past Medical History (PMH), Surgical History (PSH), Medications (MEDS), Allergies, Social History (SH), and Family History (FH)

Summarize relevant patient information that may impact current treatment. Example: "Information reviewed with patient and in EMR, no new updates."

Physical Examination

Include observations from the physical exam, even if specific exams were not performed. Example: "Constitutional: Well-appearing, no acute distress."

Assessment and Plan

Provide a concise assessment of the patient's condition and outline the proposed management plan. Example: "Prostate cancer (C61) - Stable on active surveillance; plan: continue surveillance with repeat biopsy in 6 months."

Orders, Follow-Up, and Future Considerations

Note any specific orders or follow-up plans. Example: "Follow-up in 6 months with repeat biopsy; no further considerations based on current literature."

Short Summary

A brief overview of the patient's status and management plan. Example: "The patient is a 65-year-old male with low-risk prostate cancer on active surveillance; continue with current management plan."

Incorporating AI medical scribes like Notis AI Medical Scribe into clinical practice can significantly streamline the documentation process. Notis leverages advanced voice-to-text technology to generate structured SOAP notes efficiently, saving urologists time and reducing administrative burdens.

Notis excels in time efficiency, offering potential reductions in documentation time by up to 80%, equivalent to saving approximately 2 hours per day. This is particularly beneficial in the fast-paced environment of urology, where clinicians must balance patient care with extensive documentation requirements.

With its high accuracy in transcribing medical notes and seamless integration via familiar platforms like WhatsApp, Notis ensures that urologists can maintain focus on patient interaction while effortlessly capturing detailed clinical notes. Furthermore, its support for multiple languages and comprehensive document analysis capabilities make it a versatile tool in any urological practice.

By adopting AI solutions such as Notis, urologists can enhance their documentation processes, improve patient care, and mitigate burnout associated with excessive administrative tasks. This integration of technology represents a promising advancement for the future of medical documentation in urology and beyond.