Urology Consult

Template structure

This is the structure Notat follows when it writes the note from the visit — you never fill it in by hand.

Urology Consult

Date/Time: [Insert date and time of consult]

Reason for consult: [Insert concise statement of why urology was consulted, who requested it, and the specific issue to be addressed]

Patient identification: [Insert patient name, age, gender, brief relevant background (e.g., “with a history of … presenting with …”)]

History of present illness:
(Begin with the chief complaint and duration. Then provide a chronological, problem-oriented narrative that focuses on the reason for consultation. Group related symptoms into coherent separate paragraphs rather than a single block of text. For each main problem or symptom cluster, explicitly address where available: onset, duration, tempo/progression, location and radiation, quality, severity, aggravating and relieving factors, associated symptoms, and key negatives. Include relevant baseline function, prior episodes, relevant past investigations or imaging, prior treatments and response, and any recent triggers. Comment on relevant risk factors for the presenting problem when available. Summarize functional impact where available.  End with a review of systems related to the presenting problem)

[Paragraph 1]

[Paragraph 2]

[Review of systems specific to the speciality]

Review of systems:
(hyphenated list)
- General: [e.g., weight change, fevers, fatigue]
- Genitourinary: [e.g., dysuria, hematuria, frequency, nocturia, incontinence]
- Gastrointestinal: [e.g., bowel habits, abdominal pain]
- Other systems as relevant: [e.g., cardiovascular, pulmonary]

Past Medical History:
(Hyphenated list)

Medications:
(Hyphenated list)
- [Medication name, dose, route, frequency if mentioned]
- [e.g., Metformin 500 mg oral BID]

Allergies:
(Hyphenated list)
(If no known allergies, state exactly “No known drug allergies (NKDA)”)

Family History:
(Hyphenated list)
- [Relative]: [Condition or pertinent finding]
- [e.g., Mother: breast cancer]

Social History:
(Hyphenated list)
- Tobacco: [type, amount, duration, quit date if applicable]
- Alcohol: [type, amount, frequency]
- Recreational substances: [type, frequency]
- Occupation: [current job, exposures]
- Living situation: [who lives with patient, home environment]

Physical examination:
(hyphenated list)
- [Vital signs in one line if mentioned (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)]
- General: [e.g., well‐appearing, in no acute distress]
- Abdominal: [e.g., soft, non‐distended, tenderness (location) or none]
- Genitourinary/external genitalia: [e.g., no masses, erythema, discharge]
- Rectal (if performed): [e.g., prostate size, nodularity, tenderness]
- Other systems as relevant

Investigations:
(hyphenated list)
- Laboratory studies: [e.g., Serum creatinine __ mg/dL, PSA __ ng/mL]
- Imaging: [e.g., Renal ultrasound—findings; CT abdomen/pelvis—findings]
- Other studies: [e.g., Urodynamics, cystoscopy]

Assessment & Plan:
(Use medical terminology if appropriate. Do not fabricate.)
[One‐sentence summary including patient age, sex, and primary urologic issue]

#) [Assessment as a numbered item] 
- [Hyphenated list with each corresponding plan item on a new line]