Hematuria Evaluation Note

Date/Time: [Encounter date and time]

Location: [clinic / ED / inpatient consult]

Referring clinician: [Referring clinician name, specialty] (Only include if applicable)

Referral question: [Specific question or reason for referral] (Only include if applicable)

Chief concern: [Microscopic hematuria / Gross hematuria]

History of Present Illness

Hematuria characterization: [Type: gross / microscopic], confirmed by [microscopy / dipstick only]. Onset [date/timeframe], [intermittent / persistent]. (If gross: [Color/appearance: pink / red / tea / cola], [Stream timing: initial / terminal / total], [Clots: present / absent].) [Trigger/context: exercise / trauma / recent illness / recent instrumentation / none identified].

Associated symptoms: [Dysuria], [Frequency], [Urgency], [Flank pain/colic], [Fever/chills], [Obstructive voiding symptoms], [Constitutional symptoms: weight loss, night sweats]. (Include only symptoms explicitly reported; omit this paragraph if none.)

Potentially reversible causes considered: [Recent/active UTI], [Recent instrumentation], [Vigorous exercise], [Menstruation or vaginal bleeding], [Known stones or recent passage]. (Document presence/absence when relevant; note plan to repeat UA after resolution if applicable. Omit if none considered.)

Glomerular/medical renal features: [Edema], [Hypertension], [Foamy urine], [Known CKD], [Recent streptococcal or other infections]. (Include only if present or specifically evaluated.)

Malignancy risk factors: Smoking: [current / former / never], [pack-years], [quit date if former]. Occupational exposures: [aromatic amines / benzene / dyes / rubber / none]. [Prior pelvic radiation: yes/no], [Cyclophosphamide/ifosfamide exposure: yes/no], [Chronic catheter history: yes/no], [Personal history of urothelial cancer or RCC], [Family history of urothelial cancer or RCC].

Anticoagulant/antiplatelet therapy: [Agent(s) and dose], [Indication]. (Patients on anticoagulation require the same risk-stratified evaluation; do not attribute hematuria solely to these agents.)

Prior evaluation: [Prior UA microscopy with RBCs/hpf and dates], [Urine culture results and dates], [Prior imaging with key findings and dates], [Prior cystoscopy with key findings and dates]. (Omit if no prior workup.)

Relevant Medical and Surgical History

• [CKD], [Diabetes], [Hypertension], [Coagulopathy], [Recurrent UTIs], [Nephrolithiasis], [BPH], [Urologic malignancy], [Prior urologic surgery], [Prior pelvic radiation], [Prior cystoscopy findings]. (Include only pertinent positives.)
• Family history: [Bladder cancer], [Upper tract urothelial cancer], [RCC], [Hereditary cancer syndromes]. (Specify relationship and age at diagnosis when available.)

Medications and Allergies

• Medications: [Reconciled medication list, highlighting anticoagulants/antiplatelets].
• Allergies: [Drug allergies], [Contrast allergy with reaction type]. (Include contrast allergy only if imaging with contrast is being considered.)
• Renal function: Creatinine [___] mg/dL, eGFR [___] mL/min/1.73 m² [/ Pending / Unknown]. (Document when relevant to imaging decisions.)
• Pregnancy status: [Not applicable / Negative / Positive / Unknown]. (Include only when relevant to imaging choices.)

Review of Systems

• Genitourinary: [Targeted GU symptoms as reported].
• Constitutional: [Fever / chills / weight loss / night sweats].
• Flank/back pain: [Present / Absent].
• Edema: [Present / Absent].

Physical Examination

• Vitals: BP [___/___], HR [___], Temp [___]. (Include additional vitals only if clinically relevant.)
• Abdomen: [Soft / Tender / Masses / Distension], suprapubic tenderness [present / absent].
• CVA tenderness: [Right / Left / Bilateral / Absent].
• GU exam: [External lesions], [Meatal source of bleeding]. (Include only when performed.)
• Prostate exam: [Size / consistency / nodules / tenderness]. (Include only when performed for LUTS evaluation.)
• Pelvic exam: [Findings]. (Include only if gynecologic source suspected.)

Objective Data

(Include only completed results. Do not list tests that are only planned.)

• Urinalysis:
  • Dipstick: Blood [___], Protein [___], Leukocyte esterase [___], Nitrites [___].
  • Microscopy: RBCs [___]/hpf (required for risk stratification), WBCs [___]/hpf, Bacteria [___], Squamous cells [___], Casts [___], Crystals [___].
  • RBC morphology: [Dysmorphic / Acanthocytes / Isomorphic / Not reported].
  • Specimen: [Clean-catch midstream / Catheterized], microscopy by [lab / point-of-care].
  • Limitations: [Menstruation / Many squamous cells / None]. (If significant contamination, note plan for repeat specimen.)
• Urine culture: [Result with organism and sensitivities / No growth / Pending], collected [date].
• Labs: Creatinine [___] mg/dL, eGFR [___] mL/min/1.73 m². (If gross hematuria or anemia concern: Hgb [___] g/dL, Hct [___]%.)
• Imaging: [Modality, date]: [Key findings including hydronephrosis, masses, stones, filling defects].

Risk Stratification

• Classification: [Gross / Microscopic] hematuria, [Persistent / Resolved], confirmed by microscopy.
• Risk category (microscopic hematuria): [Low / Intermediate / High / Cannot assign] per AUA/SUFU criteria.
• Rationale: [One-line justification citing age, RBCs/hpf, smoking history, and pertinent risk factors].
• (If data missing: State missing elements and plan to obtain them before finalizing risk stratification.)

Assessment

Hematuria

[Type: gross / microscopic], [RBCs/hpf], [key associated findings]. Impression: [urologic source suspected / glomerular disease suspected / uncertain etiology].

Differential diagnosis:

• Malignancy (bladder, upper tract, RCC): [Supporting and refuting findings].
• Nephrolithiasis: [Supporting and refuting findings].
• Infection/inflammation: [Supporting and refuting findings].
• BPH/prostatic bleeding: [Supporting and refuting findings].
• Glomerular/medical renal disease: [Proteinuria, dysmorphic RBCs, RBC casts, edema, HTN, CKD findings].
• Gynecologic source/contamination: [Supporting and refuting findings]. (Include only if considered.)

Plan

Evaluation Strategy

• Microscopic hematuria – Low risk:
  • Repeat UA with microscopy in [timeframe], [specimen type].
  • No immediate cystoscopy or imaging.
  • Escalation triggers: [persistent hematuria / increased RBCs/hpf / new risk factors / gross hematuria / concerning symptoms].
• Microscopic hematuria – Intermediate risk:
  • Cystoscopy: [Ordered / Scheduled / Patient deferred (reason)].
  • Upper tract imaging: [Renal and bladder ultrasound / Alternative (rationale)].
• Microscopic hematuria – High risk:
  • Cystoscopy: [Ordered / Scheduled / Completed (date/findings)].
  • Axial upper tract imaging: [CT urogram / MR urography / Retrograde pyelography]. (If CTU contraindicated, document reason and alternative.)
  • Renal function: [adequate for contrast / contraindication]. Contrast allergy: [present (reaction type) / absent].
• Gross hematuria:
  • Evaluation urgency: [urgent (instability/retention/anemia) / expedited outpatient].
  • Cystoscopy: [urgent inpatient / outpatient scheduled].
  • Upper tract imaging: [CT urogram preferred / alternative if contraindicated (reason)].
  • Acute management: [bladder irrigation / catheterization / none needed]. (Include only if clots or retention present.)

(Select only the pathway matching the patient's risk category and hematuria type.)

• Urine cytology/tumor markers: [Ordered / Not indicated]. (Adjunct only; does not replace cystoscopy.)
• Nephrology referral: [Indicated for proteinuria/dysmorphic RBCs/RBC casts/eGFR decline / Not indicated]. Urologic evaluation will [proceed concurrently / await nephrology input].

Treatment of Identified Causes

• UTI: [Antibiotic regimen and duration]. Mandatory repeat UA with microscopy after treatment to confirm hematuria resolution.
• Stones: [Management plan]. (Do not use as sole explanation for hematuria without explicit reasoning and follow-up plan.)
• BPH: [Management plan and follow-up].

(Include only causes actively being treated.)

Shared Decision-Making

• Options discussed: [Observation with repeat UA / Cystoscopy / Ultrasound / CT urogram / Other].
• Benefits and risks reviewed: [Diagnostic yield vs missed malignancy risk], [Procedure discomfort/complications], [Contrast/radiation risks], [Cost/logistics].
• Patient preferences: [Summary of patient values and concerns].
• Decision: [Chosen option(s)].
• Contingency: [Criteria triggering escalation if symptoms change or hematuria persists].

(Required when options exist or guideline-recommended testing is deferred.)

Follow-up and Safety-Netting

• Results communication: [Portal / phone / follow-up visit] by [timeframe].
• Follow-up intervals: Repeat UA by [date], follow-up visit in [timeframe].
• Return precautions: Recurrent/new gross hematuria, clots or urinary retention, fever, severe flank pain, new or worsening urinary symptoms.

Orders

• [UA with microscopy]
• [Urine culture]
• [Serum creatinine/eGFR]
• [CBC]
• [Cystoscopy]
• [Imaging: Renal/bladder ultrasound / CT urogram / MR urography]
• [Referrals: Urology / Nephrology]

(Include only orders actually placed.)

Missing Information

• Data needed: [Items required for risk stratification or imaging decisions].
• Actions taken: [Tests/records ordered to obtain missing data].
• Interim plan: Definitive evaluation plan pending receipt of above information.

(Include only when key data is unavailable. Omit section if all required information is present.)