CAKUT/Abnormal Renal Imaging Follow-Up Note (Pediatrics)

Date/Time: [encounter date and time]

Patient: [name, MRN, DOB, age in years and months]

Visit Type: [outpatient clinic / telehealth / phone]

Provider: [name and credentials]

Referring/Co-managing Clinicians: [PCP, urology, others as applicable]

Historian: [patient / caregiver / outside records] (Note interpreter use if applicable.)

Reason for Visit

[One sentence stating the specific renal finding and follow-up intent] (If the reason is unclear from referral or records, state this uncertainty explicitly.)

History

Interval Summary: [1–2 sentence summary including baseline anomaly/phenotype, laterality, time since last visit, and interval stability or change]

UTI/Infectious history:

• [Number of UTIs since last visit with dates] ([reported / culture-confirmed]; [febrile / afebrile])
• [Treatment(s) given and response; breakthrough infections on prophylaxis if applicable]
• (If information unavailable, explicitly document unavailability.)

Voiding and bowel function: (Include only when hydronephrosis, VUR, or recurrent UTIs are present.)

• [Daytime urinary symptoms: frequency, urgency, holding, incontinence]
• [Enuresis and stream concerns]
• [Bowel habits: constipation/encopresis; toileting independence]

Blood pressure:

• [Home BP monitoring results if obtained; device type and cuff size when known]
• [Symptoms suggestive of hypertension only if present]
• [Current antihypertensives and adherence]

Growth and hydration: [Appetite, weight trajectory, fluid intake patterns, activity tolerance]

Renal function and symptoms: [Interval AKI or dehydration episodes; nephrotoxin exposures; edema, hematuria, flank pain, or changes in urine output if present]

Medications: [Current medications with doses; adherence to prophylactic antibiotics and/or antihypertensives; OTC/supplement exposures including NSAIDs; allergies]

Interval imaging and specialty visits: [Studies completed since last visit with dates and facility; urology or other specialty recommendations; pending or scheduled imaging]

Baseline CAKUT description: [Established diagnosis/phenotype, laterality, prenatal history if relevant, prior surgeries] (Reference chart for unchanged details. Include family history only when relevant to current surveillance decisions.)

Objective

Vitals: [Blood pressure with arm, position, and cuff size; repeat readings if initial elevated; percentile interpretation when available or note if unavailable] [Heart rate, respiratory rate, temperature as relevant]

Growth: [Height, weight, BMI (ages ≥2) or weight-for-length (<2 years) with percentiles] (Use WHO for birth–2 years and CDC for ≥2 years.) [Trajectory: stable / crossing percentiles / improving / worsening]

Exam: (Focused to kidney disease; for telehealth, explicitly note exam limitations.)

• [General appearance and hydration status]
• [Cardiovascular exam]
• [Abdomen/flank exam]
• [Edema: present / absent]
• [Additional systems only if clinically indicated]

Data Reviewed: (If key surveillance data is missing, document whether not obtained, not available, or not applicable.)

• Labs: [Serum creatinine and/or cystatin C with eGFR; electrolytes; urinalysis; urine protein- or albumin-to-creatinine ratio; urine culture if UTI occurred]
• Imaging: [Study modality, date, facility, key findings]
  • Renal ultrasound: [kidney length with interval change, parenchymal appearance, APRPD, calyceal/ureteral dilation, bladder findings, UTD postnatal category or SFU grade] (If clinician assigns UTD category from measurements, label as clinician-assigned.)
  • VCUG: [VUR grade and laterality]
  • Nuclear studies: [drainage parameters, split renal function, scarring]

Assessment & Plan

Global Assessment: [Summary of anomaly phenotype, current risk tier, and stability across surveillance domains: BP, growth, UTI risk, renal function, imaging]

[Problem 1]: [Diagnosis or surveillance focus]

Status: [stable / improving / worsening / uncertain] with supporting data and dates.

Working diagnosis: [Concise statement; if uncertain, specify what will clarify]

• Monitoring: [Intervals for labs, imaging, BP with timeframes]
• Treatment: [Medication changes with rationale]
• Coordination: [Co-management with urology or other services; referrals]
• Education: [Key points discussed with family/caregiver]
• Follow-up: [Next visit timing; triggers for earlier return]

[Problem 2]: [Diagnosis or surveillance focus]

(Repeat structure for additional problems in order of clinical severity.)

Condition-specific documentation: (Include only when applicable.)

• Solitary kidney: [Compensatory hypertrophy status; surveillance plan for BP/proteinuria/function/ultrasound; sports activity counseling with shared decision-making]
• Hydronephrosis: [UTD category or SFU grade with key measurements; VCUG/functional imaging status (done / planned / deferred with rationale); urology involvement; next imaging date]
• Dysplasia/hypoplasia/scarring: [Kidney size and parenchymal findings; CKD staging if applicable; proteinuria/BP surveillance plan]
• Incidental findings: [How discovered; radiology recommendation; follow-up plan communicated to family and PCP]

Orders placed: [Labs, imaging, referrals with timeframes]

Follow-up: [Interval and specific triggers for earlier reassessment]

Return precautions discussed: [fever/UTI symptoms, flank pain, gross hematuria, decreased urine output, edema, severe headache or vision changes]

Signature: [electronic signature with credentials]