What documents do I need for a pelvic exam?

External Genitalia: Hair distribution, labia majora and minora, Bartholins and Skenes glands (often grouped with urethra and abbreviated BUS), hymen, introitus, perineum. Note any masses, lesions, excoriation, erythema, tenderness or discharge.

How do you document patient general appearance?

Appearance

1. Age: Does the patient appear to be his stated age, or does he look older or younger?
2. Physical condition: Does he look healthy?
3. Dress: Is he dressed appropriately for the season?
4. Personal hygiene: Is he clean and well groomed, or unshaven and unkempt, with dirty skin, hair or nails?

How do I document Heent exam?

Documenting a normal exam of the head, eyes, ears, nose and throat should look something along the lines of the following: Head – The head is normocephalic and atraumatic without tenderness, visible or palpable masses, depressions, or scarring. Hair is of normal texture and evenly distributed.

What are 97 guidelines?

The 1997 documentation guidelines describe two types of comprehensive examinations that can be performed during a patient’s visit: General multi-system examination and Single organ examination. A general multi-system examination involves the examination of one or more organ systems or body areas.

What does a complete gynecological exam consist of?

The pelvic exam in your gynecological exam is comprised of four main steps: the external genital exam, the speculum exam, the Pap Smear test and the bimanual exam.

How do you document assessment?

An assessment report should accomplish the following:

1. Outline the student learning or program outcomes or goals assessed during the assessment cycle timeframe.
2. Identify and describe the specific assessment method(s) and tools used to gather evidence for the outcomes or goals.
3. Identify the specific source(s) of the data.

How do you document skin assessment?

A skin assessment should include the presenting concern/compliant with the skin, history of the presenting concern/compliant, past medical history, family history, social history, medicines (including topical treatment) and allergies and impact on quality of life.

How do I document a skin assessment?

What is the difference between 1995 and 1997 EM guidelines?

Unlike the 1995 rules, the 1997 version allows physicans to document an extended HPI by commenting on the status of three or more chronic or inactive problems. On the other hand, the 1995 rules state that the physician must use the so-called elements of HPI when completing the history.

What are the 5 parameters of a comprehensive skin assessment?

There are five key areas to note during a focused integumentary assessment: color, skin temperature, moisture level, skin turgor, and any lesions or skin breakdown.