Documenting a urology list
Operation notes, catheter and trial-of-void plans, discharge letters and histology result letters.
Day one after a TURP
Day one post TURP for BPH. Comfortable. Irrigation stopped at six, urine light rosé.
Obs: thirty-six seven, heart rate seventy, BP one forty on eighty-two, sats ninety-seven on room air. Abdomen soft, bladder not palpable.
Hb 134, sodium 138.
Impression: uncomplicated day one after TURP.
Catheter out this afternoon for a trial of void. Bladder scan after the void, residual under 150. Oral fluids two litres today. Histology to follow, result letter to the GP. Home if voiding well.
What the list produces
- Operation note
- Cystoscopy findings, resection weight, the irrigation and catheter left in, and the post-operative orders.
- Discharge letter
- Fluids, what to expect from haematuria over the first weeks, no heavy lifting or straining, and when to present to emergency.
- Histology letter
- To the GP once the chips are reported, with the PSA plan if anything incidental is found.
