Overactive Bladder/Urinary Incontinence Management Note

Date/Time: [Date and time of encounter]

Clinician: [Clinician name, credentials]

Location: [Clinic site or telehealth platform]

Visit Type: [initial evaluation / follow-up / pre-procedure counseling / procedure / post-procedure]   Modality: [in-person / telehealth]

[Telehealth-specific limitations and local testing arrangements] (Include only if telehealth; state exam components deferred and any planned local UA/culture, PVR, or vitals.)

Chief Complaint

[One-sentence chief complaint in patient's words when available] (Use quotation marks for direct quotes.)

Subjective

[Symptom characterization] (Address: urgency with triggers and ability to defer; daytime frequency contextualized by fluid intake; nocturia frequency and sleep/safety impact; incontinence episodes and type; pad usage; voiding/emptying symptoms; severity, bother, and trajectory. Include bladder diary or questionnaire results when available with instrument name and score.)

[Relevant contributing factors] (Include only factors relevant to this patient: fluid/caffeine patterns, constipation, obesity, diabetes, diuretics or SGLT2 inhibitors, mobility or cognitive limitations, prolapse or atrophy, neurologic history, recurrent UTIs, prior pelvic surgery or radiation.)

[Prior evaluation and treatment history] (Summarize UA/culture history, PVR values with method and dates, imaging or urodynamics if performed. Document prior treatments: behavioral measures with adherence and benefit; medications tried with dose, response, adverse effects, and reason stopped; procedural therapies including PTNS, onabotulinumtoxinA, and SNM with outcomes.)

Objective

Vitals: [Relevant vital signs] (Include BP prominently if beta-3 agonist therapy is being considered or used.)

Exam: [Pertinent findings] (Include abdominal exam; pelvic exam when performed noting atrophy, prolapse, pelvic floor tone; cough stress test if evaluating stress component; focused neurologic exam if indicated. For telehealth, state exam deferred and specify what was not assessed.)

Data: [UA/culture interpretation with date]; [PVR value, method, date]; [bladder diary or questionnaire summary if obtained]; [imaging, urodynamics, or other relevant results] (Include only completed results.)

Assessment

(Numbered problem list in descending clinical priority. Specify OAB phenotype as wet vs dry; note urgency vs stress vs mixed incontinence with predominant component; include elevated PVR/retention risk and modifiable contributors. When diagnosing OAB, briefly note how alternative diagnoses were excluded.)

1. [Problem]: [Diagnosis] — [Brief supporting rationale]
2. [Problem]: [Diagnosis] — [Brief supporting rationale] (Include additional problems only if addressed.)

Plan

(Organize by problem. For each, state goals, selected interventions, and follow-up plan.)

[Problem]: [Goal or outcome target]

• Behavioral/conservative: [Measures recommended, previously tried, or declined—bladder training, pelvic floor PT, fluid/caffeine modification, weight management, constipation management]
• Pharmacotherapy: [Options discussed; patient preference; rationale for chosen agent] — [Medication name, dose, frequency]; [expected onset]; [key side effects reviewed]; [stop/hold instructions] (Include only if medication therapy discussed.)
• Antimuscarinic safety (if prescribing): [Cognitive status/dementia risk]; [anticholinergic burden]; [constipation baseline]; [glaucoma type or "not assessed"]; [retention risk/baseline PVR]
• Beta-3 agonist safety (if prescribing): [Baseline BP]; [severe uncontrolled HTN screening]; [retention risk if combined with antimuscarinic]
• Procedural therapy (if applicable): [PTNS / onabotulinumtoxinA / SNM] — [Rationale for escalation]; [pre-procedure safety items: UTI status, baseline PVR, CIC willingness for Botox; candidacy reasoning and trial plan for SNM; protocol and outcome measure for PTNS]; [counseling provided and patient decision]
• Procedure details (if Visit Type = procedure): [Procedure name]; [anesthesia]; [key steps]; [findings]; [complications]; [post-procedure instructions]
• Post-procedure assessment (if Visit Type = post-procedure): [Symptom response]; [retention assessment/PVR]; [adverse events]; [therapy adjustments]
• Orders: [UA/culture/PVR/labs/imaging ordered]; [referrals placed]
• Follow-up: [Timing and purpose] (Anchor to treatment: early review after starting medication; post-Botox check for response and retention; end-of-PTNS-induction evaluation; SNM device surveillance.)

[Additional Problem]: [Goal]

• [Plan elements as above] (Include only if additional problems addressed.)

(Limit content to information explicitly documented in the encounter. If contraindication-relevant items were not assessed, document as "not assessed" rather than omitting.)