Urology Office Visit Note (SOAP)

Date: [Date]

Patient: [Patient name or identifier]

Provider: [Clinician name and credentials]

Visit Type: [new / established]; [in-person / telehealth]

Referring Provider/Reason: [Referring clinician and reason] (Only include if this is a referral; omit this line otherwise.)

Subjective

Chief Complaint: [Chief complaint] (Use patient's own words when helpful; keep concise.)

HPI: [HPI narrative] (Summarize problem type [new evaluation / follow-up / surveillance / post-op], symptom chronology and severity, prior evaluations and treatments with response, and comorbidities affecting urologic care such as anticoagulation, CKD, retention risk, or cancer history. Tailor details to the presenting problem: for LUTS, cover voiding and storage symptoms and medication trials; for hematuria, cover timing, risk factors, and prior workup; for stones, cover pain characteristics, infection concerns, and stone history; for UTIs, cover culture results, recurrence pattern, and relevant anatomy.)

Relevant History: [Pertinent medical/surgical history, medications, allergies, and exposures] (Include only items that affect today's visit. Emphasize urologic surgeries/procedures; current medications relevant to GU care such as anticoagulants, alpha-blockers, anticholinergics; and allergies. Include family history of GU malignancies or stones if relevant. For hematuria evaluations, include tobacco and occupational exposures.)

ROS: [Pertinent positives and negatives] (Focus on GU symptoms—dysuria, frequency, urgency, nocturia, incontinence, hematuria, retention, flank pain—and relevant constitutional symptoms. Only include if it meaningfully affects the differential or management; omit if noncontributory.)

Objective

Vitals: [Vital signs as relevant]

Exam: [Focused physical exam findings] (Document pertinent findings from general appearance, abdominal exam, flank/CVA assessment, and GU/DRE exam as indicated. For sensitive exams, note chaperone present, declined, or not applicable. Only document areas actually examined; do not record presumed normal findings.)

Data: [Labs, imaging, pathology, urodynamics/PVR, and POC tests reviewed with dates and key findings] (Include only results actually reviewed today. Note point-of-care tests performed in clinic with results.)

Assessment

(List only problems addressed today, in clinical priority order. For each, state status and brief supporting evidence. Include differential diagnosis when uncertainty meaningfully affects management.)

1. [Problem 1]: [new / established]; [stable / improving / worsening] — [Concise supporting evidence from symptoms, exam, and/or data; differential if applicable]
2. [Problem 2]: [new / established]; [stable / improving / worsening] — [Concise supporting evidence; differential if applicable]

Plan

(Organize by problem. For each, include applicable elements: diagnostics with clinical question, medications with dose/duration/rationale, procedures planned, patient counseling and shared decision-making, referrals, follow-up timing with pre-visit testing, and return precautions. If clinically important information was not obtained, note reason and plan to obtain.)

1. [Problem 1]: [Diagnostics, therapeutics, counseling, and follow-up plan]
2. [Problem 2]: [Diagnostics, therapeutics, counseling, and follow-up plan]

E/M: [MDM / Time] — [If MDM: key data reviewed and risk-bearing decisions; if Time: total clinician minutes on encounter date, excluding separately billable procedures]