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normal pelvic exam template
the pelvic exam is a vital part of every woman’s preventative care and is also important towards making a number of diagnoses when presenting with abdominal or pelvic complaints. here we cover each aspect of the pelvic exam and demonstrate both in text and in our video how this done.
these include the: 4. touch speculum onto patient’s thigh to see if temperature appropriate then insert speculum at slight angle into vagina above finger and rotate to level position as it’s inserted note: a little bleeding (especially if patient nulliparous) after a pap smear is expected. o hospitalized patients – given a proper exam table with leg rests is often not available, if possible delay this exam until patient can be seen in clinic. if yeast vulvovaginitis is suspected, you or patient can obtain a swab and look under microscope or send to lab.
common smart phrases/clinic templates for general ob/gyn (created by faculty physicians) pelvic exam: external genitalia reveal normal bus and vulva. pelvic exam is a important part of the exam for female patients and important towards making various diagnoses such as yeast vulvovaginitis, bacterial vaginosis data base sample: physical examination inferior and middle turbinates – normal pharynx and tonsillar fossa: normal inspection of cervix and vagina- θ bulging with straining, nl vaginal mucosa, cervix pink., pelvic exam sample report, pelvic exam sample report, gyn exam documentation example, pelvic exam documentation template, gyn physical exam write up
normal pelvic exam template format
expanded problem focused exam – a limited exam of the affected body area or organ system and any other symptomatic or related body area(s) or organ system(s). the elements of the exam related to each body area and organ system are identified by bullets (•). the points to remember for the detailed exam are 12 bulleted elements and at least two systems or body areas. * *while the guidelines say explicitly that you must perform all the elements of the exam identified by bullets in the nine or more systems or body areas you examine, they require that you document only two per system or area.
for an expanded problem focused exam, the threshold is six elements identified by a bullet in one or more organ system(s) or body area(s). this is more stringent in that it raises the bar from eight to nine and requires documenting two exam elements for each system or area examined, but it is less stringent at least in that you can now count organ systems and body areas. that said, some physicians do attempt to organize their notes to facilitate the reviewer’s counting of hpi elements covered, systems examined, and so on. a person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference.
assessment of the gynecologic history and the pelvic examination is part of the assessment of female patients in many clinical contexts. in the 1995 documentation guidelines, the level of exam depends, simply pelvic examination (with or without specimen collection for smears and cultures), including: include equally specific notes of normal (negative) findings if they are fggt and the pelvic exam case report forms. when the document all colposcopic findings (normal and further documentation of colposcopic (and naked., ear exam documentation example, female gu exam documentation example, female gu exam documentation example, normal prostate exam documentation, heent exam documentation example, pelvic exam sample report, gyn exam documentation example, pelvic exam documentation template, gyn physical exam write up, ear exam documentation example, female gu exam documentation example, normal prostate exam documentation, heent exam documentation example
normal pelvic exam template download
the patient appeared alert.eyes: the conjunctiva was clear. the pupil was equal and reactive. the irides appeared normal.ears, nose and throat: the ears and the nose appeared normal in appearance. the oropharynx showed that the mucosa was moist. tonsil or posterior pharynx.neck: the neck was supple.
the extremities showed no edema.breasts: breast inspection showed them to be symmetrical with no nipple discharge. palpation of the breasts and axilla revealed no obvious mass that i could appreciate.gastrointestinal: the abdomen was soft, nontender with no rebound, no guarding, no enlarged liver or spleen. the uterus appeared to be normal in size and there was no cervical motion tenderness.lymphatic: there was no appreciated node that i could feel in the groin or neck area.musculoskeletal: the head and neck by inspection showed no obvious deformity. range of motion appeared to be normal for the upper and lower extremities.skin: inspection of the skin and subcutaneous tissues appeared to be normal. sensation was grossly intact by touch.psychiatric: the patient was oriented to time, place and person. the patient’s judgment and insight appeared to be normal.