Pelvic Exam Documentation Template
Get a free Pelvic Exam Documentation Template to streamline your clinical documentation. Plus, learn the importance of a pelvic exam in this guide.
Fact Checked by Ericka Pingol.
The pelvic region and its functions
The pelvic region serves as a vital component in both the male and female human body, housing a number of crucial reproductive and digestive system organs.
In women, the pelvis contains the uterus, vagina, cervix, and parts of the bowel and bladder, whereas, in men, it accommodates the prostate and parts of the bowel and bladder. It has various functions that contribute to the overall health and well-being of an individual, including the following (Mayo Clinic, n.d. a; Pelvic Floor First.,n.d.):
- Supporting the upper body's weight: The pelvis acts as a stable base for the spine and supports the upper body's weight, allowing for proper posture and movement.
- Protecting internal organs: The pelvic bones provide a protective barrier to vital organs such as the bladder, reproductive organs, and parts of the digestive system.
- Facilitating sexual intercourse and childbirth: The pelvic floor muscles help to control bladder and bowel movements, as well as aid in sexual function and childbirth.
- Helping urination and defecation: The pelvic floor muscles are crucial in controlling the body's release of urine and feces.
- Assisting with balance and stability: The pelvis works together with other structures, such as the spine, muscles, and ligaments, to maintain balance and stability while standing, walking, or engaging in physical activities.
Printable Pelvic Exam Documentation Template
Download this Pelvic Exam Documentation Template for doctors or nurse practitioners to document your patients' exam results in minutes.
Common pelvic region issues
As with any other part of the body, issues that may require medical attention can arise in the pelvic region. These issues can range from minor discomfort to more serious conditions such as infections, tumors, or reproductive disorders. Some of the most common pelvic region problems include (Johns Hopkins Medicine, n.d.):
Pelvic inflammatory disease (PID)
This is a common and often preventable infection that occurs in the female reproductive organs. It is typically caused by sexually transmitted infections (STIs), such as chlamydia or gonorrhea, which can be transmitted through unprotected sexual activity. If left untreated, this infection can lead to complications and long-term health issues.
Pelvic floor dysfunction
This condition occurs when the pelvic floor muscles become weak, tight, or torn, leading to problems with bladder and bowel control, as well as sexual function. It can be caused by factors such as pregnancy and childbirth, surgery in the pelvic region, chronic constipation or straining during bowel movements, and high-impact physical activities.
Endometriosis
Endometriosis is a chronic condition where the tissue that normally lines the inside of the uterus, known as the endometrium, grows outside of it. This misplaced tissue can attach to other organs, such as the ovaries, fallopian tubes, or intestines, leading to pain, inflammation, and potentially affecting fertility.
Uterine fibroids
Uterine fibroids, also known as non-cancerous growths, are common in the uterus and can lead to heavy or painful periods. Additionally, these growths can exert pressure on surrounding organs, causing discomfort and potential complications.
Urinary tract infections (UTIs)
UTIs are common infections in the urinary tract and can affect any part of the system, including the bladder, kidneys, or urethra. While not exclusive to pelvic health, UTIs can be a recurring issue for some individuals and may require medical intervention.
Pelvic organ prolapse
This condition occurs when one or more pelvic organs, such as the bladder, rectum, or uterus, drop from their normal position and push against the vaginal wall. This can cause pelvic discomfort and affect urinary or bowel function.
Endometrial polyps
Endometrial polyps are growths that form on the inner lining of the uterus and can cause abnormal vaginal bleeding or spotting. While they may not always be symptomatic, larger polyps or those located in some regions of the uterus may require removal.
Menstrual cramps
Menstrual cramps, also known as dysmenorrhea, are a common complaint among individuals with periods. They can range from mild discomfort to severe pain and may be caused by the release of hormones and prostaglandins during menstruation.
While some of these issues may not have noticeable symptoms, regular pelvic exams can help detect them early. By getting a yearly pelvic exam, individuals are taking an essential step in maintaining their reproductive health and preventing potential complications. It is especially crucial for women to get regular pelvic exams if they are sexually active or have a history of gynecological issues.
Conducting a pelvic exam
Pelvic exams are typically conducted by healthcare professionals such as doctors or nurse practitioners. Here are some of the components that are usually included in a pelvic exam (Long, 1990):
- External genitalia inspection: The healthcare professional will visually examine the external anatomy of the vulva, including the labia, clitoris, and vaginal opening.
- Speculum examination: A speculum is a tool that is used to gently insert into the vagina to provide a clearer view of the cervix and vaginal walls. This allows the healthcare professional to check for any abnormalities, such as discharge or lesions.
- Bimanual examination: During this part of the exam, the healthcare professional will use their fingers to feel for any abnormalities in the uterus and ovaries. They may also check for cervical motion tenderness, a sign of infection or inflammation.
- Pap smear: This is a common screening test for cervical cancer. During a pelvic exam, the healthcare professional will use a small brush or spatula to collect cells from the cervix for analysis.
- Digital rectal examination: In some cases, a digital rectal exam may be performed to check for any abnormalities in the rectum or prostate gland (in men).
- To ensure accurate and thorough documentation of a pelvic exam, healthcare professionals often use a standardized template, like a Pelvic Exam Documentation Template, specifically designed for this type of examination. This helps to ensure that all necessary components are assessed and documented.
How to use Carepatron's free Pelvic Exam Documentation Template
Our free Pelvic Exam Documentation Template makes it easy for you to document your patients' exam results in minutes. Follow these steps to get started:
Step 1: Access our free form
Get a copy of the Pelvic Exam Documentation Template using the link on this page or via the Carepatron app. You can also access it from our resources library.
Step 2: Print or use the digital format
You can print out the template and fill it in by hand or use our digital format to type in the details directly.
Step 3: Review and customize
Take a few minutes to review the template and make any necessary modifications to fit your practice's needs. You can also add your logo or clinic information for a more professional touch.
Step 4: Use the template during exams
During a pelvic exam, use the template to document your findings and any relevant information, such as patient complaints or concerns.
Step 5: Save and store for future reference
Once completed, make sure to save the document for future reference. You can store it digitally in your patient's electronic health records or print it out and add it to their physical file.
Pelvic Exam Documentation Template example (sample)
Our team has created a sample Pelvic Exam Documentation Template, showcasing how it can be used and what information is typically included. This example is for educational purposes only and should not be used as a substitute for medical advice or diagnosis. Feel free to view it here or download a PDF copy.
Download this free Pelvic Exam Documentation Template example here
Tips for effective pelvic exam documentation
Clinical documentation is a vital aspect of the healthcare profession, and proper pelvic exam documentation is no exception. Here are some tips for creating thorough and accurate records that are beneficial for both patient care and professional practice:
- Utilize a documentation template: Using a standardized template can help ensure that all necessary information is included, making it easier to compare results from previous exams.
- Use anatomical landmarks: When describing findings or noting abnormalities, use anatomical landmarks to provide precise information about the location of the body.
- Include both upper and lower extremities: A comprehensive pelvic exam also includes a brief assessment of the patient's upper and lower extremities, including muscle strength, deep tendon reflexes, and sensation.
- Be thorough with speculum examination: When performing a speculum exam, be sure to inspect all areas of the cervix and vaginal vault for any abnormalities or discharge.
- Document external genitalia and oral mucosa: In addition to the pelvic area, it is essential to document any findings on the external genitalia, as well as a quick inspection of the oral mucosa for signs of infection or lesions.
- Assess for cervical motion tenderness: This can indicate pelvic inflammatory disease and should be noted in the records.
- Double-check your findings: Remember to confirm any abnormalities with the patient and document their insight into their health.
Other related tests
While a pelvic exam is important in assessing your patient's reproductive health, it is often supplemented by other tests to understand their overall health status. These tests may include:
Blood pressure check
Regular monitoring of blood pressure is a critical part of any health screening. This simple test can help detect conditions like hypertension early, enabling timely intervention and management.
Cranial nerve assessment
This involves examining the 12 cranial nerves to ensure they are functioning correctly. Abnormalities in these nerves can indicate various conditions, ranging from neurologic disorders to infections.
Muscle strength testing
This test is used to ascertain the physical strength of a patient, indicating their overall muscle health and functionality. Any unusual weakness could indicate underlying health conditions, such as muscular disorders or nerve damage.
Nipple discharge examination
In certain cases, especially for women, an examination of nipple discharge may be necessary. This can help identify any abnormal discharge which may be a symptom of conditions like breast cancer or infection.
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References
Johns Hopkins Medicine. (n.d.). Pelvic Pain. https://www.hopkinsmedicine.org/health/conditions-and-diseases/pelvic-pain/
Long, W.N. (1990). Pelvic Examination. In H.K. Walker, W.D. Hall, J.W. Hurst (Eds.), Clinical Methods: The History, Physical, and Laboratory Examinations (3rd ed., Chapter 177). Boston: Butterworths. https://www.ncbi.nlm.nih.gov/books/NBK286/
Mayo Clinic. (n.d.). Pelvic Floor Physical Therapy Benefits. Mayo Clinic Health System. https://www.mayoclinichealthsystem.org/hometown-health/speaking-of-health/pelvic-floor-physical-therapy-benefits
Mayo Clinic. (n.d.). Pelvic Exam. Mayo Clinic. https://www.mayoclinic.org/tests-procedures/pelvic-exam/about/pac-20385135
Pelvic Floor First. (n.d.). Working Your Pelvic Floor. Pelvic Floor First. https://www.pelvicfloorfirst.org.au/pages/working-your-pelvic-floor.html
Commonly asked questions
You should document the results of your exam in a detailed and organized manner using a Pelvic Exam Documentation Template. This should include the patient's general appearance, any masses or lesions noted on the external genitalia, speculum examination findings, cervical motion tenderness, presence of any discharge, and results of a Pap smear.
You can easily customize the template to fit your needs and preferences. This can include adding or removing sections, changing the layout, or including any additional information that may be relevant to your practice.
A pelvic exam should be performed as part of a routine check-up for female patients or if the patient is experiencing any symptoms related to the reproductive system. It may also be ordered if there are concerns about sexually transmitted infections or cervical cancer.
