How does it work?
To make the most of our Speculum Exam template in your clinical practice, you can follow these steps:
Step 1: Download the template
A copy of the printable Speculum Exam template can be accessed and downloaded by doing either of the following:
- Clicking the “Use template” or “Download template” button above
- Searching for the “Speculum Exam” in Carepatron's template library on our website or app
Step 2: Go over reminders
Before conducting the test, the required basic information—such as the patient's name, examiner's name, and exam date—should be completed. Then, the reminders on the template should be reviewed and instructions followed, including explaining the Speculum Exam to the patient and obtaining their consent. This is essential for patients with a prior history of sexual trauma or gynecological conditions.
To determine if this will be helpful to you or if you would like to make any edits, we've added reminders to the template below.
- Introduce yourself to the patient. Tell them your name and role.
- Ask for the patient's name and date of birth for confirmation.
- Explain why you need a chaperone and how the exam will go in a language they'll understand. Don't forget to ask for their verbal consent.
- Ensure that they've passed urine and have told you if they're experiencing pelvic pain or may be pregnant by asking them about either once more.
- Provide them with as much privacy by allowing them to undress in a separate room and cover themselves with a sheet while lying on the clinical examination couch or exam table.
- Before you begin, reassure them that you can stop immediately if it becomes too uncomfortable for them.
Step 3: Conduct the test
After the patient understands what the test entails, the necessary equipment should be gathered, including:
- Speculum
- Gloves
- Lubricant
- Sample Pot
- Endocervical Brush
For a refresher, here are the instructions for a speculum examination.
- Cover the exposed area.
- Inspect the vulvar anatomy and external genitalia (including labia majora, labia minora, and clitoral hood) for any scars, abnormalities, pubic hair distribution, etc.
- Wear gloves.
- Lubricate the speculum.
- With your non-dominant hand, part the labia, and with your dominant hand, gently insert the speculum. The screw must be facing sideways, and the blades must be vertical.
- Rotate the speculum 90 degrees or until the screw faces upwards and the blades horizontal.
- Tighten the screw to keep the speculum open and inspect the cervix and vaginal canal, including the posterior vaginal fornix and cervical canal.
- You can swab or do a Pipelle biopsy to collect cell samples with your dominant hand or gloved finger. You can also palpate the the vaginal introitus using your index finger to assess for any abnormalities or tenderness.
Step 4: Record the results
After conducting the test and allowing the patient to dress, any observed abnormalities can be recorded. Alternatively, if none are observed, the chosen methods of sample collection can be indicated. This may include cervical cytology results or signs of cervical motion tenderness. Feel free to write down any additional notes in the space provided, including any other findings such as indications of bacterial vaginosis or suspected ovarian cancer.
You can also leverage this pelvic exam template to enhance the thoroughness and accuracy of your assessments. This tool ensures that all necessary details are documented, promoting comprehensive and precise patient care. This includes findings from a bimanual examination or rectovaginal exam when indicated.
