Urology Consultation Note (Inpatient/ED)

Date/Time of Evaluation: [Date and time of evaluation]

Author/Service: [Name, credentials, and service]

Patient Location: [ED / ICU / inpatient unit and room]

Consult Mode: [in-person / telephone advice / chart review]

Requesting Clinician/Service: [Name and service]

Consult Request

Consult Question: [Verbatim or near-verbatim consult question] (If unclear, state source and uncertainty, e.g., "Consult question not clearly specified; per RN, concern for urinary retention.")

Clinical Scenario: [urinary retention / hematuria or clot retention / obstructing stone with AKI / post-operative GU complication / GU trauma / other]

Acuity: [emergent / urgent / routine] — [One-line justification]

Key Constraints: [Anticoagulation status, solitary/transplant kidney, pregnancy, recent urologic instrumentation, immunosuppression] (Include only if applicable; state "None identified" or "Unknown" if appropriate.)

Clinical Summary

[Single-sentence orientation: age/sex, key comorbidities, current setting, immediate trigger for consult, and one objective anchor such as PVR, creatinine trend, hemoglobin trend, or key imaging finding]

History of Present Illness

[Problem-focused narrative beginning with the consult problem and timeline, detailing what changed and what was tried prior to urology involvement]

Historian: [patient / family / chart / primary team] (Note limitations if applicable.)

(Tailor details to clinical scenario:)

• (For urinary retention: time of last void, baseline LUTS, prior retention, PVR values, catheterization attempts with size/type/complications, contributing medications or neurologic factors.)
• (For gross hematuria: gross vs microscopic, clots, catheter patency, anticoagulant use and timing, recent instrumentation, infection symptoms, risk factors.)
• (For obstructing stone: fever/sepsis markers, flank pain, creatinine trend, urine output, solitary kidney or transplant status, pregnancy.)
• (For post-op complications: procedure and date, POD, catheter/stent/drain status, output characteristics, wound issues.)
• (For GU trauma: mechanism, pelvic fracture, blood at meatus, ability to void, prior catheter attempts.)

Interventions prior to urology involvement: [Brief summary of attempts and outcomes] (Include only if interventions were attempted.)

Focused Review of Systems

(Include only if it adds information beyond the HPI; otherwise omit this section entirely.)

• Genitourinary: [Relevant positives and negatives]
• Constitutional: [Fever, chills, malaise]
• Gastrointestinal: [Nausea, vomiting, constipation]
• Neurologic: [Saddle anesthesia, focal deficits] (Include only if cauda equina concern.)

(If ROS unobtainable, document reason.)

Relevant History

• PMH: [Bleeding disorders, CKD, malignancy, BPH, stones, neurogenic bladder, other pertinent conditions]
• PSH: [Urologic and pelvic surgeries with dates]
• Urologic History: [Prior stones, strictures, retention, UTIs, malignancy surveillance]
• Medications: [Current medications; explicitly note anticoagulants/antiplatelets with last dose timing, alpha-blockers, nephrotoxins]
• Allergies: [Drug, latex, and contrast allergies with reaction type]
• Social: [Smoking pack-years; occupational exposures if hematuria workup]
• Family History: [Stone disease, GU malignancy] (Include only if directly relevant.)

(If history deferred due to emergent intervention, state: "Detailed history deferred; will obtain after stabilization.")

Physical Examination

(If telephone consultation only: "No physical examination performed; telephone consultation only.")

• General: [Appearance and level of distress]
• Hemodynamic: [Stability and key vitals if pertinent to urgency]
• Abdomen: [Distension, suprapubic tenderness, peritonitis signs]
• Flanks: [CVA tenderness present / absent]
• GU: [External genitalia, meatus inspection, catheter presence and function, urine appearance]
• DRE: [Findings] (Include only if clinically indicated; document if deferred or refused.)
• Neurologic: [Saddle sensation, lower extremity strength] (Include only if cauda equina concern.)

(For sensitive exams, note medical necessity and chaperone presence per policy.)

Data Reviewed

• Vitals/I&O: [Key vitals driving urgency; urine output trends if AKI or obstruction]
• Labs: [UA with microscopy and culture status; CBC with hemoglobin trend; BMP with creatinine trend; coagulation studies if relevant] (Present as key findings with trends, e.g., "Cr 1.1 → 2.4 over 24h.")
• Imaging: [Study, date, and key findings] (State whether independently reviewed or via radiology report. Note laterality, hydronephrosis grade, stone level, perinephric stranding, bladder clots/mass as applicable.)

(If imaging pending: "[Study] pending; recommendations will be updated after review.")

Assessment

(Prioritized problem list, highest acuity first.)

[Problem 1]: [Working diagnosis or leading differential]

• Severity/Acuity: [stable / unstable]; [complicated / uncomplicated]
• Key Supporting Evidence: [Concise supporting exam and data findings]
• Important Exclusions: [Key negatives affecting management]
• Rationale for Urgent Intervention: [Clinical rationale if recommending emergent decompression, transfusion, stopping anticoagulation, or operative intervention] (Include only if applicable.)

[Problem 2]: [Working diagnosis or leading differential]

(Include additional problems as applicable.)

• Severity/Acuity: [As above]
• Key Supporting Evidence: [As above]
• Important Exclusions: [As above]

Plan

(Organize by problem, matching Assessment order.)

[Problem 1]

Urology:

• [Immediate stabilization and escalation triggers]
• [Diagnostics: now vs later, with contingencies]
• [Therapeutics: catheter management (type, size, gravity vs CBI), antibiotics, pain control, anticoagulation plan]
• [Procedures: bedside vs OR/IR, prerequisites and timing]
• [Disposition and follow-up timing]
• [Safety net: "Call urology if..." thresholds—fever, worsening pain, no urine output, catheter obstruction, hemoglobin drop, hemodynamic instability]

Primary team:

• [Actions for primary service to execute]

[Problem 2]

(Include additional problems as applicable, with Urology and Primary team sections.)

Bedside Procedure Performed

(Include this section only if a bedside intervention was performed; otherwise omit entirely.)

• Procedure: [Name of procedure]
• Indication: [Clinical indication]
• Consent: [verbal / written / emergency exception] (Note capacity or surrogate if applicable.)
• Technique: [Sterile prep, anesthesia/analgesia, key steps]
• Equipment: [Catheter type, French size, balloon volume, other devices]
• Findings/Outcome: [Urine return, volume drained, clot burden, patient tolerance]
• Complications: [None / describe]
• Post-procedure Instructions: [Catheter care, monitoring parameters, CBI discontinuation criteria]

Communication and Follow-up

• Discussed with: [Name, role, service, time and mode of communication, acknowledgment]
• Urology's Ongoing Role: [following daily / reassess at specified time / signing off with PRN availability]
• Follow-up Plan: [Reassessment timing, criteria for CBI discontinuation or catheter removal, outpatient follow-up needs with timeframe, pending results and responsible party]