Urology Follow-Up/Surveillance Visit Note

Date: [Encounter date]

Encounter Type: [office visit / telehealth] (If telehealth, include patient and provider locations.)

Clinicians: [Rendering provider] (Include trainee or scribe if present.)

Reason for Follow-Up: [Single-phrase reason for surveillance follow-up]

Interval History

(Begin with a timeframe anchor: "Since last visit on [date]" or "Since [procedure] on [date]." Use concise narrative. Omit categories with nothing to report unless clinically meaningful.)

[Interval events since anchor date: hospitalizations, ER visits, infections, stone events, procedures, new diagnoses]

[Current symptoms pertinent to the surveillance condition]

[Medication adherence and adverse effects if medications being monitored]

[Validated symptom score if used: current value compared to prior value with dates]

Objective

Vitals: [BP, HR, other as relevant] (Include if obtained; prioritize when monitoring medications with hemodynamic effects.)

Exam: [Focused exam findings] (Include only elements actually examined; do not auto-populate normals.)

Data Review: [Surveillance-relevant labs, imaging, pathology, and prior procedure results with dates] (Present as dated trend when multiple data points exist. Mark pending results as pending. Use brief clinically meaningful summaries rather than full report text.)

Procedure Today: [Procedure name, indication, key findings by anatomic area, specimens obtained, tolerance] (Include only if procedure performed this visit.)

Assessment & Plan

(List problems in order of clinical severity.)

[Problem 1]: [Diagnosis]

Status: [improved / stable / worsening / recurrent] — [Brief supporting evidence from history and objective findings]

Plan: [Management changes; next surveillance test with explicit timeframe or target date; escalation criteria if applicable]

[Problem 2]: [Diagnosis]

(Include additional problems only if addressed this visit. Follow same format as above.)

Patient Instructions: [When to call the office; when to seek emergency care]

Time-Based Billing: [Total minutes spent] (Include only if billing by time rather than MDM.)