Nephrolithiasis/Nephrocalcinosis Clinic Note (Pediatric)

Date: [Date]

Patient: [Patient name and MRN]

Provider: [Clinician name, credentials]

Visit Type: [new evaluation / follow-up] for [nephrolithiasis / nephrocalcinosis / both]

Historian: [patient / parent/guardian; note reliability if relevant]

Chief Complaint: [one-line reason for visit]

History

[Interval course or presenting history narrative] (Begin with a brief paragraph summarizing the interval course since last visit or the presenting history if new. Include timing, key events, and current symptomatic status.)

[Integrated pertinent details relevant to stone/nephrocalcinosis care] (Integrate naturally without enumerated lists: stone/nephrocalcinosis timeline; interval symptoms; diet and fluid history including sources and supplements; current medications with adherence/side effects; relevant past medical history; family history including genetic testing; adherence context such as school hydration access. Include only domains with pertinent content.)

Objective

Vitals: [weight, height, BMI percentile, BP; pain score if obtained]

Exam: [problem-focused findings] (Document only elements performed: general appearance, hydration, abdominal exam, CVA tenderness as relevant. Do not auto-populate normal findings.)

Data Reviewed:

• Labs: [relevant serum and urine results with dates] (Note "pending" if results are awaited and affect decisions.)
• Metabolic urine studies: [24-hour urine results if available—volume, pH, calcium, oxalate, citrate, uric acid, sodium, creatinine; collection date and adequacy] (Defer interpretation to Assessment.)
• Imaging: [modality, date, key findings including stone size/location, hydronephrosis, nephrocalcinosis grade] (If multiple studies, use brief chronological format.)
• Stone analysis: [composition and date if available] (If unavailable, state "stone analysis not available" and whether capture is planned.)

Assessment

(Numbered problem list in priority order. For each problem, state status and provide brief synthesis. Reference Data Reviewed rather than repeating values.)

1. [Primary stone/nephrocalcinosis problem]: [laterality, burden, symptomatic status, suspected/known etiology] — [new / stable / improved / worsening]
2. [Metabolic risk factors if identified]: [e.g., hypercalciuria, hypocitraturia, hyperoxaluria, low urine volume] — [new / stable / improved / worsening] (Do not infer without documented data.)
3. [Complicating factors if present]: [e.g., obstruction history, recurrent UTI, CKD, solitary kidney, genetic condition] — [new / stable / improved / worsening]
4. [Growth/nutrition considerations if relevant]: [impact on dietary plan] — [new / stable / improved / worsening]

Plan

(Organize by problem. Distinguish what was decided today, what was ordered, and home instructions. Avoid growth-impairing dietary recommendations.)

Recurrence prevention

• Fluid goals: [target urine output and practical daily schedule—school, sports, bedtime]
• Diet targets: [specific sodium reduction strategies; adequate dietary calcium with meals; oxalate/citrate strategies only if metabolically indicated]
• Pharmacotherapy: [medication, dose, monitoring plan, side effect counseling] (Include only if indicated.)
• If stone type unknown: [general prevention bundle and triggers for stone-specific therapy]

Metabolic evaluation

• Urine testing: [analytes, number of collections, collection instructions, timing for repeat]
• Serum testing: [labs ordered and indication]
• If deferred: [rationale and timing to revisit]

Diet/fluid counseling

• [Specific counseling provided tied to metabolic risks and growth needs]
• Concrete target: [at least one behavior-level goal, e.g., "carry 24 oz bottle at school, refill once"]
• Dietitian: [referral placed / previously established / not indicated]

Symptom management

• Pain regimen: [home analgesia plan]
• Stone straining: [instructions and where to bring sample]
• Urine culture: [when to obtain]

Follow-up

• Next visit: [interval and purpose]
• Monitoring: [timing for labs/imaging recheck]
• Care coordination: [urology, PCP, genetics, dietitian communications]

Safety-net instructions

• Go to ED: fever with flank/abdominal pain, uncontrolled pain, persistent vomiting, reduced urine output/anuria, gross hematuria with clots or retention, concern for obstruction
• Call clinic urgently: recurrent gross hematuria without systemic symptoms, new urinary symptoms, stone passage, medication side effects
• After-hours: [contact pathway]

Orders placed

• [Labs — indication]
• [Imaging — indication]
• [Referrals — indication]
• [Medications — dose and indication]

(Do not infer stone composition or metabolic abnormalities without documented results. Prefer omission over placeholders for non-critical missing data. Do not add ROS or exam elements solely for billing.)

Time: [total time if coding by time] (Include only if coding by time.)