Proper documentation of a pelvic examination serves as a comprehensive medical-legal record and is a fundamental component of quality patient care. Clear, standardized charting ensures continuity of care across different healthcare providers and institutions, offering an objective timeline of a patient’s reproductive health. The record must be legible, timely, and reflect all observations made during the physical assessment. Accurate documentation defends the clinician’s actions and treatment decisions, providing necessary detail for insurance, billing, and medical review.
Pre-Examination Documentation
Before the physical assessment begins, the medical record must establish the context and legal preparation for the pelvic examination. Documentation starts by noting the patient’s chief complaint or the specific indication for the examination, such as an annual screening, abnormal bleeding, or pelvic pain. This information justifies the procedure and guides the focus of the physical assessment.
A record of informed consent is necessary, confirming that the patient understands the nature of the examination and has agreed to proceed. The presence of a chaperone, if one was offered or utilized, must be documented, as this is standard practice to ensure patient comfort and professional conduct. Details of the patient’s positioning, typically the dorsal lithotomy position with feet in stirrups, should also be noted.
The preparatory documentation must also include relevant patient history that could influence findings, such as the date of the last menstrual period (LMP) and any significant prior gynecological surgeries. Recording this administrative and historical data sets the stage for the physical findings that follow. This ensures that clinical observations are interpreted within the context of the patient’s health narrative.
Documenting External and Speculum Findings
The visual inspection phase requires highly specific documentation, beginning with the external genitalia. This record should detail the hair distribution, the appearance of the labia majora and minora, and the condition of the perineum. Any lesions, masses, excoriations, or signs of inflammation, such as erythema or swelling around the Bartholin’s or Skene’s glands, must be precisely described by size and location.
Moving to the speculum examination, documentation first describes the vaginal vault, noting the color of the mucosa, the presence of rugae (folds), and any signs of atrophy, masses, or prolapse (e.g., cystocele or rectocele). The type and character of any vaginal discharge are recorded objectively, using terms like “thin and gray,” “thick and white,” or “frothy and yellow-green.”
The documentation then focuses on the cervix, describing its position, color, and surface characteristics. The appearance of the cervical os should be noted as either “pinpoint” (nulliparous) or “slit-like” (multiparous). Any discharge, bleeding, or observed lesions, such as polyps or nabothian cysts, must be documented with accurate descriptions of size and location. If specimens are collected (e.g., for a Pap smear or STI testing), the documentation must explicitly state the type of sample taken and the exact collection site.
Documenting Bimanual and Palpation Findings
The bimanual examination documentation shifts to tactile findings, beginning with the cervix. The record should describe the texture and consistency of the cervix (e.g., “firm” or “soft”) and note the presence or absence of cervical motion tenderness (CMT) when the cervix is gently moved. This assessment is relevant because CMT can be a sign of pelvic inflammatory disease.
The documentation then details the assessment of the uterus, including its size, contour, consistency, mobility, and position. Uterine size is often estimated in terms of gestational weeks (e.g., “10-week size”), and the position is noted as anteflexed, retroverted, or mid-position. Any irregularities in contour, such as nodularity suggesting fibroids, or any tenderness upon palpation, must be clearly recorded.
Documentation of the adnexa (ovaries and fallopian tubes) is often challenging but must be attempted. The record should state whether the adnexa were palpable and, if so, describe any masses found, noting their size, mobility, and tenderness. Normal ovaries are often non-palpable, and this finding should be recorded as “adnexa non-tender, non-palpable bilaterally.” If a rectovaginal examination is performed, the record must include findings on the cul-de-sac, rectal tone, and any masses or tenderness noted in the posterior pelvis.
Post-Examination Summary and Planning
The final documentation phase synthesizes the findings into a formal Assessment and Plan. The Assessment section includes the working diagnosis or a list of differential diagnoses that explain the patient’s symptoms and the physical exam findings. This step reflects the thought process that correlates the documented observations with established medical conditions.
The Plan outlines the proposed course of action, which may include prescriptions, referrals to specialists, further diagnostic testing, or specific follow-up instructions. Any medications prescribed or procedures performed, such as endometrial biopsy or intrauterine device insertion, must be documented in detail. This section also includes procedure codes (CPT codes) related to specimen collection, which are necessary for accurate medical billing.
Patient education provided during the visit is an integral part of the Plan and must be documented, including discussions about expected test results, signs of worsening conditions, and when to seek further care. Completing the record with a thorough Assessment and Plan ensures the patient’s visit closes with a clear analytical summary and a defined path forward. This transition from descriptive findings to actionable steps is the last necessary component of a complete pelvic exam record.