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Genitourinary Specialist
10-15 minutes

Post-Prostatectomy Evaluation Template

The Prostatectomy Follow-up template by s10.ai is expertly crafted for urologists to efficiently document patient visits post-prostate surgery. This comprehensive template encompasses sections for chief complaints, prostate cancer history, recovery milestones, and a thorough assessment and plan. It is invaluable for monitoring postoperative progress, including urinary continence, erectile function, and PSA levels. By ensuring meticulous documentation, this template enhances effective patient management and follow-up care. Perfectly suited for urologists, it streamlines the follow-up process, ensuring all vital aspects of the patient's recovery and ongoing care are meticulously addressed.

1,949 uses
4.2/5.0
M
Michael Thompson
Template Structure

Organized sections for comprehensive clinical documentation

(write as a urologist, moderate detail, including direct quotes from the patient where possible or applicable)
PRIMARY CONCERN:
["Patient visits the clinic today for a follow-up after prostatectomy on" [insert date of surgery in US format] "due to" [insert pathology in TNM format including gleason score and margin status]]. "He is" [time since surgery] (calculate years, months, weeks since surgery and express in conversational terms) postoperative." (note: if the patient had biochemical recurrence or received postoperative radiation therapy indicate that here)
PROSTATE CANCER BACKGROUND:
(ALWAYS INCLUDE PATHOLOGY FROM SURGERY)
[Summarize urologic history as it relates to prostate cancer in around 6 sentences (if the history is long, you can make the summary longer at your discretion, in particular if there are noteworthy events in the pre or postop period that a Urologist would think are worth remembering), starting from diagnosis and including the pre-surgical period, as well as the recovery prior to today's visit. (Include labs, pathology results, imaging, and procedures. Include physician and provider names and referring urologist name if mentioned. Include relevant data that a urologist would want to refer back to in order to quickly reorient to the patient)]
RECOVERY PROGRESS:
["- Urinary continence:" [include last known level of continence achieved and date, in terms of number of pads or diapers per day (if unknown, put "not known.")]]
["-Urinary stream:" [last known description of urinary stream and date] (if unknown, put "not known.")]
["-Erectile function:" [preop function, and last mention of postop function and date, including current treatments for ED the patient has used] (if unknown, put "not known.")]
HPI TODAY [Date of current consultation in US format]:
[- [Insert how much time has passed since prostatectomy (calculate, and say years, months, weeks, days as appropriate)]
[- [Description new changes related to the urologic conditions for which the patient is being followed (in particular new information since the last visit).]]
[- [Description of current symptoms or lack thereof (otherwise omit).]]
[- [Relevant imaging results and their interpretation. (only if available, otherwise omit. If available, always include date and location of scan, and the phrase "I personally reviewed and independently interpreted the scan and concur with findings.")]]
[- last PSA level (include PSA value, units in ng/ml, and date of lab]
[- [Relevant test results and their interpretation. (only if available, otherwise omit)]]
[PMH, PSH, MEDS, ALLERGIES, SH, and FH:
[Information reviewed with patient and in EMR, with changes made where appropriate.]
- [Any updated information related to PMH, PSH, MEDS, ALLERGIES, SH, and FH in bulleted format (only if mentioned, otherwise omit)] (entire section can be omitted if nothing relevant this visit)]
[PHYSICAL EXAMINATION:
[Constitutional: General appearance and state of distress. Level of consciousness.]
[Psychiatric: Mood and affect. Behavior. Judgment and thought content.]
[GU exam if performed]. (entire section omitted if no physical exam)]
ASSESSMENT AND PLAN:
[Patient's age and a brief 1-3 sentence summary of their condition (include TNM staging, and time since their surgery in years, months, weeks; use "man" instead of "male")]
(ALWAYS ASSESS: Prostate cancer, Stress incontinence, Erectile Dysfunction even if issue seems resolved)
1. [Prostate Cancer (Prostate cancer, C61)]
- [Assessment: Current assessment of the condition.]
- [Plan: Proposed plan for management or follow-up.]
- [Counseling: Description of the condition, natural history, or similar, (include only if discussed otherwise omit).]
2. [Stress incontinence (and ICD-10 code)]
- [Assessment: Current assessment of the condition.]
- [Plan: Proposed plan for management or follow-up.]
- [Counseling: Description of the condition, natural history, or similar, (include only if discussed otherwise omit).]
3. [Erectile dysfunction (and ICD-10 code)]
- [Assessment: Current assessment of the condition.]
- [Plan: Proposed plan for management or follow-up.]
- [Counseling: Description of the condition, natural history, or similar, (include only if discussed otherwise omit).]
4. [Medical issue 4, 5, 6, etc (condition name and ICD-10 code, only urologic issues and related issues)]
- [Assessment: Current assessment of the condition.]
- [Plan: Proposed plan for management or follow-up.]
- [Counseling: Description of the condition, natural history, or similar, (include only if discussed otherwise omit).]
ORDERS:
[List orders for labs or medications. (only if orders mentioned otherwise "No orders.")]
FOLLOW UP:
[Follow-up plan time frame including future tests ordered (only if mentioned otherwise omit)].
SHORT SUMMARY:
[2 sentence summary of today's visit including key aspects only]
(IMPORTANT: Never come up with your own patient details, assessment, plan, interventions, evaluation, plan, and counseling - use only the transcript, contextual notes or clinical note as a reference for the information include in your note.)
Sample Clinical Note

Example of completed documentation using this template

CHIEF COMPLAINT:
Patient visits the office today for a follow-up after prostatectomy on 05/15/2023 for prostate adenocarcinoma, pT2cN0M0, Gleason score 7 (3+4), with clear margins. He is 1 year, 5 months postoperative.
PROSTATE CANCER HISTORY:
The patient was diagnosed with prostate cancer in January 2023 after an elevated PSA level of 8.5 ng/ml. A biopsy confirmed adenocarcinoma with a Gleason score of 7 (3+4). Preoperative MRI showed no signs of extracapsular extension. He underwent a robotic-assisted laparoscopic prostatectomy on 05/15/2023 performed by Dr. John Smith. Postoperative pathology confirmed pT2cN0M0 staging with negative surgical margins. Recovery was smooth, and the patient was discharged on postoperative day 2. PSA levels have remained undetectable since surgery.
RECOVERY MILESTONES:
- Urinary continence: 1 pad per day as of 10/01/2024.
- Urinary stream: Strong and continuous as of 10/01/2024.
- Erectile function: Preop function was normal; currently using sildenafil with partial success as of 10/01/2024.
HPI TODAY 11/01/2024:
- 1 year, 5 months since prostatectomy.
- No new changes related to urologic conditions.
- No current symptoms.
- Last PSA level: <0.1 ng/ml on 10/15/2024.
PHYSICAL EXAMINATION:
- Constitutional: Well-appearing, no acute distress. Alert and oriented.
- Psychiatric: Mood and affect appropriate. Cooperative behavior.
ASSESSMENT AND PLAN:
65-year-old man with history of prostate cancer, pT2cN0M0, 1 year, 5 months post-prostatectomy.
1. Prostate Cancer (Prostate cancer, C61)
- Assessment: No evidence of recurrence, PSA undetectable.
- Plan: Continue PSA monitoring every 6 months.
2. Stress incontinence (N39.3)
- Assessment: Mild stress incontinence, improving.
- Plan: Continue pelvic floor exercises, consider urodynamic studies if no further improvement.
3. Erectile dysfunction (N52.9)
- Assessment: Partial response to sildenafil.
- Plan: Continue sildenafil, consider alternative therapies if no improvement.
ORDERS:
No orders.
FOLLOW UP:
Follow-up in 6 months with repeat PSA.
SHORT SUMMARY:
Patient is 1 year, 5 months post-prostatectomy for prostate cancer with no evidence of recurrence. Mild stress incontinence and partial erectile dysfunction persist, with ongoing management.
Clinical Benefits

Key advantages of using this template in clinical practice

  • This comprehensive clinical template for post-prostatectomy follow-up is designed to streamline documentation and enhance patient care for urologists. It meticulously captures the patient's journey from diagnosis through surgery and recovery, ensuring all critical data such as pathology, imaging, and lab results are readily accessible. The template includes sections for chief complaints, prostate cancer history, recovery milestones, and a detailed history of present illness, allowing for a thorough assessment of urinary continence, urinary stream, and erectile function. It also provides a structured format for physical examination findings and a detailed assessment and plan, covering prostate cancer, stress incontinence, and erectile dysfunction. By adopting this template, clinicians can ensure a comprehensive evaluation and management plan, facilitating improved patient outcomes and streamlined follow-up care.
Frequently Asked Questions

Common questions about this template and its usage

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