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Urology Specialist
15-20 minutes

Urology Inpatient Progress Note Template

The Inpatient Progress Note for Urology by s10.ai is an all-encompassing documentation template tailored for urologists overseeing inpatient care, whether post-surgical or for non-surgical admissions. This template streamlines the meticulous recording of daily patient progress, encompassing vital signs, subjective and objective evaluations, and a structured care plan. It is especially beneficial for monitoring postoperative recovery, managing urologic conditions, and coordinating discharge planning. By ensuring comprehensive documentation, it enhances communication among healthcare providers, making it an invaluable tool for urology residents and specialists. This template supports efficient patient management and elevates the standard of care, motivating clinicians to adopt and integrate it into their practice.

2,933 uses
4.5/5.0
M
Michael Thompson
Template Structure

Organized sections for comprehensive clinical documentation

DAILY PROGRESS NOTE
"Date of Service:" [today's date in US format (MM/DD/YYYY)]
"Patient:" [patient full name]
"DOB:" [patient date of birth in US format (MM/DD/YYYY)]
"MRN:" [patient medical record number without dashes]
Surgery: [name of surgery] on [date (MM/DD/YYYY)], POD [calculated postop day (day of surgery is POD 0, day after is POD 1, etc) (if no surgery has been done, omit this section)]
SYNOPSIS:
This is a [patient age and gender in conversational format] [summarize the patient's urologic situation in no more than two sentences]
INTERVAL HISTORY:
[overnight events details since the last progress note (if no significant overnight events, omit this section)]
SUBJECTIVE:
[subjective information from the patient's point of view, using direct quotes if possible or appropriate]
OBJECTIVE:
- Vital signs, last 24h: [Vital signs data in last 24 hours (include temperature, heart rate, blood pressure, SpO2, RR if available, whatever isn't available omit (omit vital sign section if not available)]
- Intake and Output:
[IO data in bulleted format (omit if no I/O mentioned)]
-Drains: [bulleted summary of current drains including such things as foley catheters, JP drains, internal ureteral stents, externalized ureteral stents, nephrostomy tubes, nephroureteral stents, NG tubes, and other urologic and non urologic drains pertinent to surgical care]
PHYSICAL EXAM:
[bulleted physical exam details (omit section if no physical exam mentioned)]
MEDICATIONS:
"Scheduled Meds:" [scheduled medications list (if available otherwise omit)]
"Continuous Infusions:" [continuous infusions list (if available otherwise omit)]
"PRN Meds:" [PRN medications list (if available otherwise omit)]
LABS, IMAGING, AND OTHER STUDIES:
"• Radiology: Recent imaging studies have been reviewed and are notable for" [radiology findings (if available otherwise omit)]
"• Laboratory: All recent labs have been reviewed. Pertinent labs include" [pertinent lab results (if available otherwise omit)]
"• Microbiology data: All recent micro results have been reviewed. Pertinent micro results include" [pertinent lab results (if available otherwise omit)]
ASSESSMENT/PLAN:
[Patient name] is a [Patient age and patient sex in conversational format] patient of [attending of record (if known otherwise omit] [patient condition or diagnosis, especially POD (number) if postop from a certain procedure] (here we want 1 or max 2 sentences describing exactly what a urologist would want to know about this patient at this snapshot in time)
1. [Urologic or post surgical issue 1 (condition name and ICD-10 code if applicable)]
- [Plan: Proposed plan for management or follow-up. (include only if mentioned, otherwise leave blank)]
- [Counseling: Description of the condition, natural history, or similar, only if discussed. (include only if mentioned, otherwise leave blank)]
2. [Urologic or post surgical issue 2 (condition name and ICD-10 code if applicable)]
- [Plan: Proposed plan for management or follow-up. (include only if mentioned, otherwise leave blank)]
- [Counseling: Description of the condition, natural history, or similar, only if discussed. (include only if mentioned, otherwise leave blank)]
3. Urologic or post surgical issue 3, 4, 5, etc (condition name and ICD-10 code if applicable)]
- [Plan: Proposed plan for management or follow-up. (include only if mentioned, otherwise leave blank)]
- [Counseling: Description of the condition, natural history, or similar, only if discussed. (include only if mentioned, otherwise leave blank)]
4. Fluids (always include plan with the IV fluids)
- [Current fluids and plan to change fluids if applicable]
5. Electrolytes (always include plan with the electrolytes)
- [Current electrolytes and plan to address if applicable, otherwise "Replete electrolytes PRN"]
6. Diet (always include plan with nutrition)
- [Current diet status and associated plan]
7. Prophylaxis (always include plan with prophylaxis)
- [Current DVT prophylaxis, ulcer prophylaxis, any other if mentioned or applicable]
8. Disposition (always include disposition)
- [If there is a plan for discharge or similar, mention here (if not mentioned, "Inpatient, not appropriate for discharge planning at this time.")]
ORDERS:
[List orders for labs or medications. (include only if mentioned, otherwise leave blank)]
"Signed by:"
[resident name and credentials]
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note.
“Consent for the use of AI-assisted tools for documentation was obtained from the patient and all other participants in the visit prior to this encounter. All questions were answered. Patient understands that they may decline the use of AI-assisted tools.”
Sample Clinical Note

Example of completed documentation using this template

DAILY PROGRESS NOTE
"Date of Service:" 11/01/2024  
"Patient:" John Doe  
"DOB:" 05/15/1970  
"MRN:" 123456  
Surgery: Radical Prostatectomy on 10/30/2024, POD 2  
SYNOPSIS:  
This is a 54-year-old male with a history of prostate cancer, status post radical prostatectomy, currently recovering well.  
INTERVAL HISTORY:  
No significant overnight events.  
SUBJECTIVE:  
"I feel a bit sore but otherwise okay."  
OBJECTIVE:  
- Vital signs, last 24h: Temperature 98.6°F, Heart Rate 78 bpm, Blood Pressure 120/80 mmHg, SpO2 98%, RR 16  
- Intake and Output:  
  - Intake: 2000 mL  
  - Output: 1800 mL  
- Drains:  
  - Foley catheter in place, draining clear yellow urine  
PHYSICAL EXAM:  
- Abdomen: Soft, non-tender, surgical site clean and dry  
MEDICATIONS:  
"Scheduled Meds:" Acetaminophen 500 mg PO q6h  
"Continuous Infusions:" None  
"PRN Meds:" Oxycodone 5 mg PO q4h PRN pain  
LABS, IMAGING, AND OTHER STUDIES:  
"• Radiology: Recent imaging studies have been reviewed and are notable for no acute findings."  
"• Laboratory: All recent labs have been reviewed. Pertinent labs include normal CBC and electrolytes."  
"• Microbiology data: All recent micro results have been reviewed. Pertinent micro results include no growth."  
ASSESSMENT/PLAN:  
John Doe is a 54-year-old male patient of Dr. Smith, POD 2 from radical prostatectomy.  
1. Prostate cancer, status post radical prostatectomy (ICD-10: C61)  
- Plan: Continue current pain management and monitor for complications.  
- Counseling: Discussed expected recovery timeline and signs of infection.  
2. Postoperative pain (ICD-10: G89.18)  
- Plan: Continue acetaminophen and PRN oxycodone for pain control.  
3. Foley catheter management  
- Plan: Monitor output and plan for removal on POD 3.  
4. Fluids  
- Continue IV fluids at 75 mL/hr.  
5. Electrolytes  
- Replete electrolytes PRN.  
6. Diet  
- Advance to regular diet as tolerated.  
7. Prophylaxis  
- Continue DVT prophylaxis with enoxaparin 40 mg subcutaneously daily.  
8. Disposition  
- Inpatient, not appropriate for discharge planning at this time.  
ORDERS:  
- CBC and BMP tomorrow morning.  
"Signed by:"  
Dr. Thomas Kelly, MD  
“Consent for the use of s10.ai-assisted tools for documentation was obtained from the patient and all other participants in the visit prior to this encounter. All questions were answered. Patient understands that they may decline the use of s10.ai-assisted tools.”
Clinical Benefits

Key advantages of using this template in clinical practice

  • Enhance your clinical documentation with our comprehensive Daily Progress Note template, specifically designed for urology chief residents conducting inpatient rounds. This template streamlines the documentation process for post-surgical and non-surgical urology patients, ensuring all critical information is captured efficiently. With sections dedicated to patient demographics, surgical details, subjective and objective findings, and a detailed assessment and plan, this template supports accurate and thorough patient care documentation. It includes vital signs, medication lists, lab results, and imaging studies, providing a holistic view of the patient's current status. The structured format facilitates clear communication among healthcare teams, enhancing patient management and continuity of care. Adopt this template to improve your documentation workflow, ensuring compliance and optimizing patient outcomes in the urology department.
Frequently Asked Questions

Common questions about this template and its usage

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