Creating accurate and comprehensive follow-up notes in urology is critical for effective patient care. These notes ensure continuity and provide a clear record of patient progress and treatment plans. Below, we will break down the essential components of a follow-up note using the structured SOAP (Subjective, Objective, Assessment, Plan) format, tailored for urology specialists.

Chief Complaint

Begin by documenting the patient's primary concerns. This section should be concise and directly reflect the issues that brought the patient to the clinic. For example:

Chief Complaint: Patient presents to the office today to discuss:

• Frequent urination

• Blood in urine

• Lower abdominal pain

Past Urological History

Detail the patient’s relevant medical history, focusing specifically on previous urological conditions or treatments. This includes any past diagnoses, surgeries, and ongoing management strategies:

Past Urological History: The patient, a 58-year-old man, has a history of benign prostatic hyperplasia (BPH) diagnosed two years ago. He underwent a transurethral resection of the prostate (TURP) last year, performed by Dr. Thomas Kelly. His PSA levels have been monitored regularly, with the last reading being 4.5 ng/mL six months ago.

History of Present Illness (HPI)

The HPI section provides a narrative of the patient’s current symptoms and any changes since the last visit. Include details like onset, frequency, and associated symptoms:

HPI Today [11/01/2024]:

• The patient reports an increase in urinary frequency and urgency over the past month, with occasional nocturia.

• He has noticed blood in his urine twice in the last week.

• A recent CT scan of the abdomen and pelvis was reviewed, showing mild bladder wall thickening.

Past Medical History, Medications, Allergies, Social and Family History

Summarize the patient's other medical conditions, current medications, allergies, and relevant social and family history:

PMH, PSH, MEDS, ALLERGIES, SH, and FH: Reviewed with the patient and in EMR, with changes made where appropriate. PMH: Hypertension. MEDS: Lisinopril 10 mg daily. ALLERGIES: No known drug allergies.

Physical Examination

Document findings from the physical examination. Focus on relevant systems and any abnormalities detected:

Physical Examination: GU exam reveals mild tenderness in the suprapubic region. Patient appears well-nourished and in no acute distress.

Assessment and Plan

Provide a comprehensive assessment including diagnoses and a detailed plan for each issue. This section should guide the treatment strategy:

Assessment and Plan:

• Benign Prostatic Hyperplasia (BPH) (ICD-10: N40.1): Symptoms suggestive of BPH progression. Plan: Continue monitoring PSA levels and consider medication adjustment.

• Hematuria (ICD-10: R31.9): Likely related to bladder wall changes. Plan: Schedule cystoscopy.

• Lower Abdominal Pain (ICD-10: R10.30): Possibly related to bladder irritation. Plan: Prescribe antispasmodic medication.

Orders and Follow-Up

End with a summary of any orders placed and the follow-up plan, ensuring clear next steps for patient management:

Orders: Schedule cystoscopy. Prescribe antispasmodic medication.

Follow Up: Follow-up in two weeks with cystoscopy results.

With the rapid advancements in technology, AI medical scribes like Notis AI Medical Scribe are revolutionizing how urology specialists document patient interactions. These virtual scribes significantly reduce the time spent on documentation, allowing healthcare providers to focus more on direct patient care. Notis, for instance, utilizes voice-to-text technology to transcribe patient encounters into accurate and structured SOAP notes.

Time Efficiency: Notis reduces documentation time by up to 80%, allowing urologists to save approximately 2 hours daily, thereby reducing burnout and improving productivity.

Ease of Use: Operating through a familiar platform like WhatsApp, Notis eliminates the need for learning new software, making the transition seamless for healthcare professionals.

High Accuracy: With a transcription accuracy of 99%, Notis ensures that medical notes are precise and reliable, supporting better clinical decision-making.

Comprehensive Documentation: Notis AI Medical Scribe converts patient interactions into structured SOAP notes instantly, streamlining the entire process of clinical documentation.

For urologists, integrating an AI medical scribe into their practice can lead to enhanced efficiency, more accurate medical notes, and ultimately, improved patient care.