Nephrolithiasis Evaluation & Management Note

Date/Time: [Encounter date and time]

Patient: [Patient name or identifier]

Encounter Type: [Acute episode / Prevention-focused / Post-procedure]

Provider: [Provider name and credentials]

High-Risk Flags: [solitary kidney / transplant / pregnancy / CKD / anticoagulation / None identified]

Chief Complaint

[One-line reason for visit in patient's words or concise clinical phrasing]

History of Present Illness

[Narrative of current stone episode and relevant background] (For acute visits: symptom onset/progression, pain location/laterality/severity, associated symptoms, oral tolerance, therapies tried. Include prior stone history with recurrence pattern, prior procedures, and known stone composition—write "Stone type unknown" if not documented. For prevention visits: also address fluid intake, dietary factors, relevant supplements/medications, GI risk factors, and family history.)

Objective

Vitals: [Temp, HR, BP, RR, SpO2, pain score as relevant] (State "not recorded" if not obtained)

Exam: [Pertinent findings including CVA tenderness, abdominal exam, hydration status, signs of toxicity/sepsis] (If telehealth or minimal exam, state "not performed" with reason)

Labs: [UA, serum Cr with baseline, CBC, urine culture status, pregnancy test as applicable] (List pending studies as "Ordered—pending")

Imaging Summary: [Modality and date; source (radiology report vs independent interpretation); for each relevant stone: size in mm, location, obstruction status; hydronephrosis severity; secondary signs if present; HU density and skin-to-stone distance if available for procedural planning] (If no imaging available, state "No imaging available" and address in Plan)

Assessment

Infection status: [No evidence of infection / Concern for UTI / pyelonephritis / urosepsis] (List supporting findings; flag emergency pathway if obstruction with infection signs)

Obstruction/renal function: [Hydronephrosis presence/severity; creatinine trend vs baseline; high-risk anatomy if present]

Stone characterization: [Confirmed vs suspected; ureteral vs renal; obstructing vs non-obstructing; size/location summary; passage likelihood if conservative management considered] (Use "not reported" if size/location not documented)

Symptom control: [Current pain level, treatment response, PO tolerance]

Classification: [Uncomplicated / Complicated] (Complicated if infection, refractory pain, renal insufficiency, or high-risk anatomy)

Plan

Stone management: [Selected pathway and rationale] (For conservative/MET: hydration targets, strain urine instructions, follow-up imaging plan, return precautions, MET medication/dose/duration with off-label acknowledgment and stop conditions if applicable. For urgent decompression: urology notification, cultures obtained, antibiotics, decompression method, definitive treatment deferred. For elective intervention: modality selected with rationale, pre-op requirements, stent plan.)

Pain management: [Regimen] (NSAIDs first-line if not contraindicated with renal/GI/CV considerations documented; acetaminophen; opioids only if necessary with risk mitigation; antiemetics as needed)

Prevention: [For prevention visits: stone analysis status, 24-hour urine plan, dietary targets (fluid ≥2.5 L urine/day, sodium ≤2000 mg/day, normal dietary calcium, moderate animal protein, oxalate guidance if relevant), pharmacotherapy if indicated] (For acute visits, state "Prevention deferred—follow-up scheduled")

Disposition: [Discharge with criteria met / Admission with indication] (Follow-up timeframe, planned imaging/labs, return precautions confirmed)

(Do not infer stone size, location, or composition if not documented—use "not reported" and plan to obtain. Do not infer infection clearance without supporting data. Express stone sizes in mm; include units for urine volumes and sodium targets.)