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Click ‘Get Form’ to open the pelvic exam documentation sample in the editor.
Begin by entering your name and date of birth in the designated fields. This information is crucial for identifying your medical history.
Provide your contact phone number and campus box number to ensure easy communication regarding your exam.
Indicate whether this is your first exam by selecting 'Y' for yes or 'N' for no. This helps healthcare providers understand your experience level.
Fill out the current medications and allergies sections accurately, as this information is vital for safe medical care.
In the GYN History section, record details about your menstrual cycle, including the start date of your last period and any issues you may have experienced.
Complete the contraceptive and sexual history sections honestly to provide a comprehensive view of your health needs.
Finally, review all entries for accuracy before signing and dating the form at the bottom. This ensures that all information is correct and up-to-date.

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What is important to note on inspection when examining the ?

You should then assess the various characteristics of the : Position: the may be anteverted or retroverted. Size: the should be approximately orange-sized. Shape: may be distorted by masses such as large fibroids. Surface characteristics: note if the feels smooth or nodular.

How do you describe a normal pelvic exam?

The pelvic examination includes the following: External examination of mons and . Speculum examination. Bimanual examination.

What to document on a pelvic exam?

Pelvic examination (with or without specimen collection for smears and cultures), including: Examination of external genitalia (e.g., general appearance, hair distribution, lesions) and (e.g., general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele)

How to report speculum exam findings?

There were no abnormalities noted on inspection of the and speculum examination revealed a healthy with a closed external os. In summary, these findings are consistent with a normal speculum examination. For completeness, I would like to perform the following further assessments and investigations.

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