Pelvic Exam Documentation Template

A Pelvic Exam Documentation Template is a structured tool designed to guide healthcare professionals in recording the findings of a pelvic examination. It ensures all aspects of the assessment, from the evaluation of the external genitalia to laboratory examinations like Pap smears, are systematically documented.This document aligns with established clinical methods, promoting accuracy, thoroughness, and high-quality patient care.

A pelvic examination is performed to assess symptoms such as pelvic pain, abnormal discharge, or changes in the vaginal walls. It may also be part of routine preventive care, such as screening for cervical cancer or sexually transmitted infections, or to evaluate specific conditions like pelvic organ prolapse.

Cervical motion tenderness refers to pain elicited when the cervix is gently moved away from its normal position during a bimanual examination. It can indicate underlying issues such as pelvic inflammatory disease or other gynecologic conditions, making it a critical part of a complete exam for female patients.