Pelvic Examination Note (Emergency Department)

Date/Time: [Date and time of examination]

Examiner: [Examiner name and role]

Indication: [Brief clinical reason for exam]

Pregnancy Status: [positive / negative / unknown/pending] (Include test type and timing if known.)

Chaperone: [Name and role / offered and declined by patient / unavailable due to emergent circumstance with rationale]

Consent: Verbal consent obtained for [speculum only / speculum and bimanual / specimen collection]. (Note any patient preferences or limitations discussed.)

Examination Findings

(Include only the components actually performed. Omit any subsection entirely if not performed. If a component was attempted but incomplete, document what was assessed and reason for limitation.)

External Genitalia

(Include only if examined.)

[Vulva, perineum, and introitus description] (Document presence or absence of lesions, ulcerations, erythema, swelling, discharge at introitus, bleeding, trauma, or Bartholin gland abnormality. Include location and characterization for any abnormal findings.)

Speculum Examination

(Include only if performed. Note speculum size only if visualization was limited.)

• Vaginal mucosa: [normal / erythematous / lesions present / trauma / foreign body] (Brief description if abnormal.)
• Vaginal discharge: [none / present] (If present: amount [scant / moderate / copious]; character [thin / thick / watery / curdy / frothy]; color [clear / white / gray / yellow / green / bloody].)
• Cervix: [appearance description]; os [closed / open] (Note any visible products of conception, tissue, or active bleeding at os.)
• Mucopurulent discharge: [present / absent]
• Friability: [present / absent] (Bleeding with gentle contact.)
• IUD strings: [visible / not visualized / not applicable] (Note length if relevant.)

Bimanual Examination

(Include only if performed.)

IMPORTANT: For patients with second or third trimester vaginal bleeding, do not perform digital/bimanual examination until placenta previa has been excluded by ultrasound. (Document that this precaution was considered if applicable.)

• Cervical motion tenderness: [absent / present - mild / present - moderate / present - severe]
• Uterus: [non-tender / tender]; [anteverted / midposition / retroverted]; [normal size / enlarged] (Include approximate size if enlarged.)
• Right adnexa: [non-tender / tender - mild/moderate/severe]; [no mass / mass present with description]
• Left adnexa: [non-tender / tender - mild/moderate/severe]; [no mass / mass present with description]
• Limitations: [none / limited by pain/guarding/body habitus] (Only include if applicable.)

Specimens Collected

(Include only if specimens were obtained. Omit entire section if no specimens collected.)

• Specimens sent: [Test names] from [vaginal / endocervical] site; [clinician-collected / patient self-collected]
• Point-of-care results: [pH / whiff test / wet prep findings] (Include only if performed.)
• Pending: [NAAT GC/CT / trichomonas / cultures / other]

Impression

[Concise interpretive summary] (State what findings are most consistent with, what they argue against, and any limitations affecting interpretation. Do not diagnose based on components not examined.)

Plan

• Empiric treatment: [given with medications, doses, and route / deferred with rationale]
• Testing: [Labs/imaging ordered] (Note how and when results will be communicated.)
• Partner management: [Partner notification/treatment plan if STI suspected] (Omit if not applicable.)
• Return precautions: [Worsening pain / fever / heavy bleeding / syncope / inability to tolerate PO / other] (Tailor to clinical findings.)
• Consults/Referrals: [Gynecology / infectious disease / other with reason] (Omit if none.)
• Follow-up: [Timeline and provider] (Include contraception or device follow-up if relevant.)

Pelvic Exam Deferred

(Include this section only if exam was deferred. If included, omit the Examination Findings and Specimens Collected sections.)

• Reason deferred: [Patient declined / not clinically indicated / hemodynamically unstable / other]
• Alternative evaluation: [Self-collected swabs / urine testing / imaging / specialist consult / none]

Forensic Considerations

(Include only if the encounter involves sexual assault evaluation.)

• SANE involvement: [Yes with name/role / No]
• Separate forensic record: [Yes / No] (Do not duplicate forensic documentation in this note.)