Prostate Cancer Counseling/Active Surveillance Note

Date: [Date]

Location: [Clinic or telehealth platform]

Clinician: [Name, credentials]

Visit Type: [New Diagnosis Counseling / Active Surveillance Follow-up / Re-counseling for Reclassification]

Participants: [Patient and any family, support persons, or interpreter present]

Chief Concern

[Brief patient-stated reason for visit and clinician framing in 1–2 sentences]

Cancer Summary

(This section is the single source of truth. Use explicit status labels—unknown, not performed, pending, records requested—for any missing elements. Do not infer pathology features or imaging interpretations. For active surveillance follow-ups, abbreviate by referencing prior documentation but include current PSA and any new pathology or imaging.)

Diagnosis Date & Method: [Date] — [Biopsy approach: transrectal / transperineal / targeted + systematic]

Pathology: Grade Group [X] (Gleason [pattern]); [Positive cores/total cores]; [Highest % core involvement]; [Laterality/location]; Adverse features: [cribriform / intraductal / perineural invasion / none identified] (If outside pathology review pending, note recommendations are provisional.)

PSA History: Diagnostic PSA [value, date]; Most recent PSA [value, date]; PSA density [value] with prostate volume [mL, source, date]

Clinical Stage & Risk Category: [Clinical T stage from DRE]; [N/M status from imaging]; Risk category: [very low / low / favorable intermediate / unfavorable intermediate / high] based on [inputs used] (If key data missing, label as provisional and note what is needed.)

Staging Workup: [mpMRI with PI-RADS, date]; [Bone scan, date]; [PSMA PET, date] — Additional staging: [indicated / not indicated / completed / pending with communication plan]

Interval History

(Include for active surveillance follow-ups. For new diagnosis visits, include only pertinent prior workup context. Omit entirely if no interval history exists.)

[New symptoms concerning for progression; changes in urinary or sexual function; patient experience on surveillance including anxiety, willingness to continue, adherence barriers; outside opinions or treatments since last visit]

Objective

Exam: [DRE findings: size, nodules, induration, symmetry] (If deferred or telehealth, state reason. Include other exam findings only if clinically relevant to decision-making.)

Results Snapshot: (Summarize key findings; do not paste full reports.)

[Most recent PSA with date]; [Most recent MRI impression with PI-RADS, dominant lesion, date]; [Most recent biopsy summary with Grade Group, cores, highest involvement, date]

Assessment

Diagnosis: Clinically localized prostate adenocarcinoma — [Clinical stage]; [Risk category]; [Key anchors: PSA, Grade Group, volume descriptors]. Secondary factors: [comorbidities, anticoagulation, life expectancy, functional priorities as relevant]

AS Candidacy: [Meets criteria / Does not meet criteria / Conditional pending confirmatory testing] (Note factors increasing reclassification risk and any confirmatory tests needed before commitment.)

Decision & Shared Decision-Making: Options discussed: [active surveillance / surgery / radiation / observation-watchful waiting as appropriate]. Patient values/priorities: [stated preferences]. Decision: [Proceed with AS / Proceed with definitive treatment / Observation-watchful waiting / Undecided pending additional information]. (Confirm patient understanding of plan.)

Plan

(Complete the relevant pathway based on decision.)

If Active Surveillance:

Surveillance Protocol: PSA every [interval], next due [date]; DRE every [interval] or [omitted with rationale]; MRI every [interval], next due [date]; Biopsy: [confirmatory needed yes/no], [transperineal / transrectal], [systematic ± targeted], timing [date]

Triggers for Early Evaluation/Conversion: [Biopsy upgrade threshold]; [Volume increase definition]; [PSA kinetics threshold]; [MRI progression criteria]; Patient preference/anxiety as valid trigger

If Definitive Treatment:

Referrals: [Radiation oncology / Urologic surgery, status]. Pre-treatment needs: [Functional questionnaires, pelvic floor PT, medical clearance, imaging completion, fertility/genetic counseling as indicated]. Timeline: [Planned dates/milestones]

If Observation/Watchful Waiting:

Rationale: [Life expectancy / comorbidities / patient preference]. Follow-up: [Symptom-driven plan]

Patient Instructions: Call for [fever after biopsy, urinary retention, severe hematuria, new bone pain, neurologic symptoms]. Results via [phone / portal / visit] within [timeframe].

Orders & Referrals: [Tests ordered]; [Referrals placed]; [Records requested with status]; [Tumor board: planned / not indicated / completed]

Time-Based Billing: (If applicable) [Total minutes] spent on [reviewing records/pathology/imaging, counseling, ordering, documentation, care coordination]. (Exclude time for separately billable procedures.)