Pelvic Exam Documentation Template

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.

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.

What do the results mean?

A pelvic exam can reveal a wealth of information about a patient's reproductive health. The results can indicate the presence of STIs, cancerous or noncancerous growths, and other conditions impacting the pelvic region (Mayo Clinic, n.d.b).

For instance, if the cervix appears inflamed, it might signify an infection or the presence of a sexually transmitted infection such as chlamydia or gonorrhea. Similarly, unusual growths or masses in the uterus could indicate the presence of fibroids or endometrial tissue, a hallmark of endometriosis.

The examination of the external genitalia and speculum exam of the vagina and cervix can provide insight into potential issues such as abnormal discharge or lesions. Cervical motion tenderness, a painful response to moving the cervix during the exam, can indicate pelvic inflammatory disease.

Additionally, a Pap smear, typically collected during the exam, is crucial for detecting precancerous changes in the cervix that could indicate a risk of cervical cancer.

It is crucial to communicate the results clearly to the patient, explaining what the findings mean for their overall health and what next steps, if any, should be considered. Additional tests may be required for a more precise diagnosis if abnormalities are found.

Regardless of the results, patients should be encouraged to continue regular screenings as part of their ongoing healthcare routine.

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:

1. 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.
2. Use anatomical landmarks: When describing findings or noting abnormalities, use anatomical landmarks to provide precise information about the location of the body.
3. 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.
4. 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.
5. 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.
6. Assess for cervical motion tenderness: This can indicate pelvic inflammatory disease and should be noted in the records.
7. 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.