Bladder Cancer Surveillance Note

Encounter Date: [Date]

Patient: [Name / MRN]

Provider: [Name, Credentials]

Location: [Clinic / Facility]

Visit Type: [Surveillance cystoscopy / NMIBC follow-up / Post-TURBT follow-up / BCG maintenance coordination / Results review]

Bladder Cancer Summary

Diagnosis: [Histology; NMIBC / MIBC / post-cystectomy status; initial diagnosis date/year]

Most Recent Pathology: [Specimen type and date; grade; stage (Ta/T1/Tis/T2); muscularis propria present and involved/uninvolved; LVI; variant features] (If pending, state "pending" with collection date—do not infer stage or grade.)

Risk Category: [Low / Intermediate / High / Very high] ([Basis for classification]) (If indeterminate due to missing pathology elements, state explicitly and identify which elements are missing.)

Intravesical Therapy: [Agent; induction/maintenance status with dates; response; tolerability] (If none, state "None.")

Prior Surveillance: [Last cystoscopy date and result; last cytology date and result; last upper tract imaging modality, date, and result]

Interval History

[Interval symptoms and clinical events since last surveillance] (Summarize hematuria, dysuria, urgency/frequency, UTIs, systemic symptoms if high-risk disease, interval procedures or hospitalizations, and intravesical therapy tolerance if applicable. Keep to a few concise sentences.)

Objective

Exam: [Pertinent findings] (Include abdominal/flank tenderness, general appearance, stoma exam if applicable. Omit line entirely if no exam performed.)

Data Reviewed: [Pathology with date; cytology with date; imaging modality with date; relevant labs with date] (List items inline, separated by semicolons.)

Cystoscopy

(Include this subsection only if cystoscopy performed today and documented in this note. If results-review only or cystoscopy documented in separate procedure note, omit entirely and use the alternative line below instead.)

Indication: Bladder cancer surveillance

Consent/Time-out: Obtained and performed

Prophylaxis: [Given / Not given—rationale]

Technique: [Flexible / Rigid] cystoscopy; [anesthesia details]

Findings: [Urethra findings; bladder mucosa findings; ureteral orifices with efflux] (For lesions: specify number, size, morphology [papillary / flat / erythematous], and location by clock-face or anatomic landmark. Note CIS suspicion if present. State whether photodocumentation captured.)

Specimens/Interventions: [Cytology: voided / bladder washing; biopsy location(s); fulguration location/size] (Omit items not performed.)

Tolerance: [Tolerated well / Complications]

Post-procedure Instructions: Return precautions discussed including fever, retention, worsening hematuria

Alternative if cystoscopy documented separately: Cystoscopy performed today—see procedure note [Note ID]. Summary: [One-line result].

Assessment

1. Bladder cancer—surveillance: [Current stage/grade]; [risk category]; [today's cystoscopy result or most recent result]; [cytology status]; [upper tract surveillance status: current / overdue]
2. Intravesical therapy status: [On induction / On maintenance / Completed / On hold / Intolerance] (Include only if applicable. If recurrence after BCG, use neutral language unless dose and date details support specific classification.)
3. [Additional problems affecting surveillance plan] (Include only if relevant to management, e.g., symptomatic LUTS, recurrent UTI.)

Plan

Surveillance schedule: [Next cystoscopy target date/window with risk-based rationale]; [cytology plan: obtained today / each visit / periodic]; [upper tract imaging: modality, interval, renal-function contingency if relevant]

Contingency pathways:

• If cystoscopy suspicious → schedule TURBT/biopsy
• If cytology positive with negative cystoscopy → enhanced cystoscopy, mapping biopsies as indicated, prostatic urethra evaluation if relevant, upper tract imaging
• If recurrence → reassess risk category, discuss treatment options including cystectomy if high-risk

Intravesical therapy plan: [Maintenance schedule / holds / dose adjustments / alternative agents] (Include only if applicable.)

Counseling: [Recurrence/progression risk discussion matched to risk category; patient preferences regarding surveillance intensity; smoking cessation if applicable]

Orders and follow-up: [Orders placed today with indication]; [follow-up appointment timing]; [communication plan for pending results]

(Use bracketed placeholders such as "[last upper tract imaging: unknown—reconcile]" when information is missing rather than omitting required fields. Do not infer stage or grade if pathology is pending or muscularis propria not identified. Maintain clear separation between procedure documentation and Assessment/Plan content.)