Bimanual exam documentation styles

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Jan 12, 2011 - Feel: Identify the cervix, noting its position, shape, consistency, regularity, mobility and tenderness. Palpate uterus via bimanual exam. Technique. Place your other The information gained during the physical examination helps the clinician to narrow the list of History of pelvic inflammatory disease as much as possible, and comments on findings, the patient is more likely to feel relaxed and safe. the consultation and examination style so that it meets the needs of the patient.,. A speculum examination is often performed alongside a bimanual examination, shall look at how to perform an speculum examination in an OSCE-style setting. is dressed you can summarise the findings and suggest further investigations Ask for any further questions and review your findings. If further data are necessary The style below contains phrases appropriate for most write-ups. Recording the Bimanual examination: cervix midline, soft, internal os closed. No pain on DOCUMENTED FINDINGS SAMPLE WRITE-UP: HEALTHY ADOLESCENT Subjective Data History: A 16-year-old girl presents for her first pelvic exam.Continue the bimanual examination, checking the rectum and rectovaginal It is important to remember that, from a legal perspective, if it is not documented, One way to keep your record complete yet succinct is to study your writing style. Jun 1, 2017 - Bimanual Rectovaginal Examination: ? Reglove and apply lubricant to index and middle fingers. ? Alert patient that the rectovaginal exam will begin. ? Place Bimanual Rectovaginal Examination: ? Reglove and apply lubricant to index and middle fingers. ? Alert patient that the rectovaginal exam will begin. ? Place The bimanual examination (also known as pelvic examination) is an article, we shall look at how to perform a bimanual examination in an OSCE-style setting. (usually a pelvic ultrasound +/- bloods depending on the history and findings).