The genitourinary (GU) assessment provides a systematic evaluation of a patient’s renal, bladder, and reproductive health status. Proper documentation ensures continuity of care, supports accurate billing, and transforms clinical observations into a cohesive narrative shared among the healthcare team. This record allows for objective measurement of patient progress and informs subsequent clinical decisions.
Essential Components of the Genitourinary Documentation Record
The documentation generally follows the established framework of Subjective Data, Objective Data, and the final Assessment and Plan of Care (A/P). The record must also include essential metadata to establish the context of the assessment. This includes the date and time the examination was performed, the specific location, and the full name and professional credentials of the examiner.
Maintaining a clear chronological order within the patient’s electronic health record (EHR) is important to track the progression or resolution of symptoms. Every entry must be clearly delineated with appropriate headings.
Documenting Subjective Data and Patient History
Documentation of subjective data begins with accurately capturing the patient’s Chief Complaint (CC), the primary reason for the visit, often recorded in the patient’s own words. The History of Present Illness (HPI) requires a detailed narrative using a structured method, such as OLDCARTS, to describe the urinary or genital symptom.
The examiner must document the Onset, Location (e.g., suprapubic, flank, urethral), Duration, and specific Characteristics (e.g., sharp, dull, intermittent). Documenting any Aggravating or Alleviating factors and associated symptoms (such as fever or nausea) provides a complete picture of the complaint.
A focused Review of Systems (ROS) must explicitly document the presence or absence of specific genitourinary symptoms. Specific positive findings include dysuria (painful urination), hematuria (blood in the urine), increased frequency, urgency, or hesitancy. Documenting negative findings, such as “Patient denies nocturia, hesitancy, and flank pain,” indicates a thorough review was conducted.
Documenting Objective Physical Exam Findings
The documentation of objective data relies on precise, standardized terminology to describe findings from inspection, palpation, and percussion of the GU system. For the renal and abdominal assessment, the record must describe the appearance of the abdomen, noting if the contour is flat, rounded, or distended, and if the skin is intact.
Palpation findings must detail the suprapubic area, noting whether the bladder is non-palpable or if fullness is detected, which could indicate urinary retention. The assessment of the kidneys includes documenting the presence or absence of Costovertebral Angle (CVA) tenderness. This is recorded as “CVA tenderness noted” or “CVA tenderness denied,” suggesting possible kidney inflammation or infection. The genital examination findings must be documented separately based on gender.
Male Patients
Documentation includes inspection of the penis for lesions, discharge, and the location of the urethral meatus. Palpation findings detail the testes, epididymis, and spermatic cord, describing the size, consistency (e.g., firm, smooth), and presence of any masses or tenderness.
Female Patients
Documentation includes the appearance of the external genitalia, noting skin integrity and the absence or presence of discharge or lesions. If a pelvic examination is performed, specific documentation of the cervix, uterus, and adnexa is required, including any observed masses, tenderness, or structural abnormalities.
Documentation of Diagnostic Results and Plan of Care
The final section of the GU documentation integrates the collected subjective and objective data with diagnostic results to formulate a clinical action plan. Key laboratory and imaging results must be documented and interpreted in the context of the patient’s presentation. For example, a urinalysis result showing positive leukocyte esterase and nitrites is documented along with the clinical interpretation that supports a diagnosis of a urinary tract infection.
The Assessment component clearly states the working or confirmed diagnosis, ensuring it is supported by the evidence recorded in the history and physical exam sections. This is followed by the Plan of Care, which outlines the immediate and long-term actions for the patient. The Plan must explicitly detail any prescribed treatments, such as medications, necessary follow-up appointments, and any referrals to specialists. Finally, documentation must confirm that patient education was provided, covering topics like medication instructions, symptom monitoring, and preventive measures.