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Male GU exam Documentation example

MALE GENITOURINARY EXAMINATION KIDNEY INSPECTION: Inspect the abdomen and flank. If the renal size is large enough, a visible mass may be seen. This is usually only seen in a child or thin adult. PALPATION: Palpate the kidney with the patient in the supine position. Push the kidney forward with the one hand in the back, and palpate the kidney wit • Recognize abnormal findings during the male genitourinary exam. • Demonstrate advanced skill in the physical exam of the male client in the reproductive health setting. • Discuss emotional aspects of conducting male exam . 7/24/2014 Typical male perception of GU problems

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Male GU Exam A normal male genitourinary exam would be dictated as follows: The testicles are descended bilaterally. They are firm, non tender, and without masses or lesions. No penile lesions are noted and there is no discharge from the urethra. The scrotum is without induration, erythema, or edema. No hernias are palpated in th Documentation for Male GU Exam Here are some suggested approaches/words to use when documenting the male GU exam. Areas to include in documentation Examples of normal variants or abnormal findings Penis and Urethral Meatus Inspect Tanner stage Presence of discharge, lesions, warts, ulcerations, scabs Statement of skin issues - erythema, excoriation Palpation Masses, tenderness Retraction of. The following examination, however, should be performed on all male patients, regardless of whether you suspect any underlying abnormality. Before palpating this region, have the patient bear down (i.e. valsalva) or cough (though have them turn their heads first so they don't expectorate into your hair) while you look at the inguinal region Examination of male genitals and secondary sexual characteristics. Step-by-Step: Male Genital Examination Clinical Summary Guide Testicular volume Testicular volume is assessed using an orchidometer; a sequential series of beads ranging from 1 mL to 35 mL (see Image 1). Testicular volume is measured using the following steps: 1 Sample Name: Normal Male Exam Template - 1. Description: An example/template for a routine normal male physical exam. (Medical Transcription Sample Report) MALE PHYSICAL EXAMINATION. HEENT: Pupils equal, round and reactive to light and accommodation. Extraocular movements are intact. Sclerae are anicteric. TMs are clear bilaterally

Normal Physical Exam Template Samples. Physical Exam Format 1: Subheadings in ALL CAPS and flush left to the margin. GENERAL APPEARANCE: The patient is a [x]-year-old well-developed, well-nourished male/female in no acute distress. VITAL SIGNS: Blood pressure [x] mmHg, pulse rate [x] beats per minute, respirations [x] breaths per minute. A Guide to the Clinical Male Urogenital Examination presents a step-by-step instructional guide for performing a basic clinical well-male exam, including a physical assessment of the testicles, penis, rectum and prostate. Clinical Skills USA, Inc. provides students and practitioners in the healthcare professions with hands-on training in. The genitourinary and rectal exam is an essential part of the overall health assessment in the male. A complete and efficient exam will lead to the identification of current or potential health problems

Genitourinary Exam medicalscrib

Obtain stool sample for occult blood test when indicated. 4. Area. Elements of Examination. Genitourinary; Genitourinary. MALE: Elements of Genitourinary Examination. Content and Documentation Requirements. Level of Exam . Perform and Document: Problem Focused . One to five Annual GYN Exam Medical Transcription Sample Reports. HISTORY OF PRESENT ILLNESS: This is a pleasant (XX)-year-old gravida 2, para 2, postmenopausal female who presents today for a routine GYN exam. She was last seen by Dr. John Doe on MM/DD/YYYY. Pap smear at that time was negative for malignancy Sample Pediatric History and Physical Exam Date and Time of H&P: 9/6/16, 15:00 Historian: The history was obtained from both the patient's mother and grandmother, who are both considered to be reliable historians. Chief complaint: The rash in his diaper area is getting worse. History of Present Illness: Cortez is a 21-day-old African American male infant who presente

parts of this GU exam. Refer to data section (table below) in order to quantify. After reviewing the medical record documentation, identify the level of examination. Circle the level of examination within the appropriate grid in Section 5 (Page 3). Neck Skin Gastrointestinal (Abdomen) Examination of abdomen with notation of presence of masses. MyDevelopmentLab Video Series. Introduction. Video. This clip demonstrates a male genital exam. Please be advised: This clip may contain sensitive content. QUESTIONS TO CONSIDER. In the clip the physician has the client cough while she palpates the inguinal area. What is she checking for Before genital exam : Inspect mouth (gums, tongue, tonsils, throat, soft and hard palate) Palpate lymph nodes ( cervical, axillary..etc) Inspect skin ( face, trunk, hands/palms, soles of feet) Preparation For Genital Exam Prepare supplies need for exam Label all specimens and slides Wash and warm hands Put on gloves Preparation For Genital Exam

Documentation for Male GU Exam - Documentation for Male GU

  1. ent lesions Hair: Normal texture and distribution
  2. ation of the male genitalia. Urological Exa
  3. ation of the older female child. Male providers should request the presence of a parent or delegate during the exa
  4. Palpate Rectum and Prostate. Palpate the prostate gland. Note the following: Palpate the rectal wall starting from the 6 o'clock position clockwise to the 12 o'clock position. Then return to the 6 o'clock position and palpate the other half of the rectal wall feeling for masses, nodules and tenderness
  5. g the Male Genital Exam - English VersionMature. Perfor

Male Genital And Rectal Exam - University of California

  1. A neuro exam is one of the more complex body systems to master when it comes to assessment and documentation. Testing the cranial nerves, for example, takes practice. Omitting a small part of the process can mean missing a potentially serious diagnosis. Given the importance of the neurological exam, today as part of our documentation Documenting a Neuro Exam, Decoded Read More
  2. ation includes documentation of 50 percent or more of the above bullets, then a detailed male GU exa
  3. ation is part of your decision making
  4. al health assessment of a healthy adult. Nurses Notes: Subjective Data: No abdo

Statement of Purpose. The genitourinary, vaginal, and rectal examinations are essential for the evaluation of the female patient. This module was developed to illustrate the basis technique and methodology of this examination. In addition, in this presentation a specific diagnosis is discussed The testicular exam is done as part of a routine physical exam or for evaluation of testicular/penile complications (e.g. pain, swelling, etc.). We describe the proper technique here 12.3 Gastrointestinal and Genitourinary Assessment. The gastrointestinal (GI) system is responsible for the ingestion of food and the absorption of nutrients. Additionally, the GI and genitourinary (GU) systems are responsible for the elimination of waste products. [1] Therefore, during assessment of these systems, the nurse collects subjective. The order of the exam should conform to the age and temperament of the child. For example, many infants under 6 months are easily managed on the examining table, but from 8 months to 3 years you will usually have more success substituting the mother's lap. Certain parts of the exam can sometimes be done more easily with the child in the pron General Assessment: The general assessment is the area of the physical exam where the physician notes the hygiene, overall general appearance and affect of the patient. Examples: The patient is awake, alert, oriented, calm, cooperative. The patient is disheveled, smells of stale urine The patient is unarousable The patient appears angry, agitated, is pacing in th

Urology SOAP Note Sample Report. SUBJECTIVE: This (XX)-year-old man is doing very well on Flomax 0.4 mg daily. He is asymptomatic and sleeps through the night. No dysuria, hematuria, frequency, urgency, or incontinence. He takes Flomax and metoprolol daily along with calcium and multivitamins. His recent PSA is 2.4 1. Annual health exam V70.0 2. Influenza vaccine V04.81 0 3. Tdap Booster V06.1- 4. Zoster vaccine V05.8 - 5. Mammogram screening V76.12 - She needs one yearly until age 75. Actue Self-limited problems 1. depression, 311 - She has been having some depressed greater than 2 weeks with some lack of interest in leaving her house April 2011 CAPRI Male Reproductive Systems Conditions DBQ Workflow 1 1 Introduction 1.1 Purpose This document provides a high level overview of the contents found on the Male Reproductiv Newborn Male Newborn Female Male less than 1 Year Female less than 1 Year Male 1 to 4 Years Female 1 to 4 Years Male over 4 Years Female over 4 Years Sports Physical. Skin: Normal turgor and without lesions. Eyes: Red reflex present bilaterally. Pupils equally round and reactive to light. Head: Normocephalic with age appropriate fontanelles

Example of a Complete History and Physical Write-up Patient Name: Unit No: Location: Informant: patient, who is reliable, and old CPMC chart. Chief Complaint: This is the 3rd CPMC admission for this 83 year old woman with a long history of hypertension who presented with the chief complaint of substernal toothache like chest pain of 12 hour document this. EXAMPLE: O2 Saturation: 88% on room air, 95% on 2 liter nasal canula. General appearance: include information on the patient's overall condition. It is appropriate to comment on level of comfort or distress, as well as general grooming and hygiene. Example: Mr. Smith is a well appearing elderly gentleman in no acute distress

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CHARTING EXAMPLES FOR PHYSICAL ASSESSMENT SKIN, HAIR AND NAILS Skin pink, warm, dry and elastic. No lesions or excoriations noted. Old appendectomy scar right lower abdomen 4 inches long, thin, and white. Sprinkling of freckles noted across cheeks and nose. Hair brown, shoulder length, clean, shiny. Normal distribution of hair on scalp and perineum -Comprehensive exam: 9 systems with 2 bullets in each system (example: 12 systems) -Very few 80 year olds have a normal exam so the normal template does NOT work -Avoid using the physical exam normal templates in older, sicker patients Physical exam documentation We recommend following the 1995 CMS coding guidelines. Under those guidelines, both 99213 and 99214 visits require two to seven of the below body areas or organ systems to be addressed. For 95 guidelines, only one exam component for that body area or organ system is required to receive credit. All the item The adult well-male examination should provide evidence-based guidance toward the promotion of optimal health and well-being. The medical history should focus on tobacco and alcohol use, risk of.

The following is an example of documentation from health assessment of the reproductive system of a 28-year-old female. Nurses Notes: Subjective Data: Client states she has had no problems with reproductive function. Menses onset at age 11. Menses q 28 days for 4 days. Gravida 1, para 1. No problems—vaginal delivery of 7 lb 6 oz female Newborn Physical Exam Medical Transcription Samples. PHYSICAL EXAMINATION: VITAL SIGNS: Weight 6 pounds 7 ounces, length 19 inches, head circumference 13-3/4 inches, and temperature 98.6. GENERAL APPEARANCE: This newborn appears to be a well-nourished, well-developed female The chart note by the NP should also document your presence or the presence of anyone else in the exam room during the exam: 'RiskManager in the exam room during GU exam' or 'Patient's spouse/parent/guardian (and their name) in the exam room during the visit'. Please don't just chart 'MA in the exam room during GU visit' without specifying the. Testicular Examination. A testicular examination is mainly performed on male patients who present with testicular pathology e.g. pain, swelling, a lump. Although titled testicular examination it involves the examination of the penis, scrotum and testes. As this is an intimate examination it is pertinent to gain a good rapport with your patient.

Sample Name: Normal Male Exam Template -

Documentation of a breast exam as part of the medical record can be found in Bates pp. 20 and 354. Another example of a normal breast examination is as follows: Breasts : Large size, left breast slightly larger than right. No dimpling noted. Granular consistency palpated bilaterally Examination of the male genitalia is an intimate activity and in this article emphasis is placed on the issues of informed consent and the importance of ensuring that each patient has a chaperone present during the examination. Detailed discussion is provided to enable the nurse to use a step-by-step approach to ensure a thorough and detailed. G. GU - frequency, dysuria, hematuria, discharge, abdominal pains, quality of C. Order of exam: least distressing to most distressing D. Rapport with child 1. Include child - explain to the child's level For example, stranger anxiety is a normal stage of development, which tends to mak

Exam Documentation: Charting Within the Guidelines -- FP

Document any change in weight. If weight loss or gain is substantial or has happened rapidly, investigate further. Dieting to a body weight leaner than recommended health standards tends to be highly promoted by current fashion trends, sales campaigns for special foods, and is encouraged in some activities and professions. Young women ar For example, more work is done (and documented) than what is performed normally during an annual preventive exam. Remember: These are recommendations, only; the patient's needs, history, and risk factors determine the extent to which counseling, anticipatory guidance, and screening services should be performed, based on the provider's. Last eye exam ----- Nose- Stuffiness Discharge Itching Hay fever Nosebleeds Sinus pain ----- Throat- Teeth Gums Bleeding Dentures Sore tongue Dry mouth Sore throat Hoarseness Thrush Non-healing sores Last dental exam Exam Guidelines. The Hospitalist. 2011 November;2011 (11) Author (s): Carol Pohlig. The extent of the exam should correspond to the nature of the presenting problem, the standard of care, and the physicians' clinical judgment. Remember, medical necessity issues can arise if the physician performs and submits a claim for a comprehensive.

Male Exam - The SOAPnote Projec

For the purposes of this study, a GU physical examination included a genital examination and/or a digital rectal examination. We also included limited examinations relevant to the consultation; for example, documentation of costovertebral angle tenderness in the case of an obstructing ureteral stone or characteristics of urine in the case of. exam of that particular region of the body. Include the description of these nodal regions with the other nodes listed after the Neck exam.) 7. Breasts: Inspection and palpation, for masses, discharge, or tenderness 8. Chest: Inspection: for symmetry of respiratory excursions; for deformities Palpation: for fremitu The clinician must be sensitive regarding the genitourinary examination of the older female child. Male providers should request the presence of a parent or delegate during the examination. At the onset of the examination of the genitalia, explain to the patient why examination of the area is needed and how it will be performed, including what.

SOAP Notes Format in EMR

Documentation of Breast Assessment Patient has the presence of both breasts, relatively equal in size with right breast slightly larger than the left. The breasts are round, color is pink, skin surface smooth in appearance. There is no dimpling or retraction noted, no redness, inflammation or increased venous engorgement noted. No lumps, lesions or rashes noted A medical history includes an evaluation of your current urinary tract symptoms, history of urinary tract infections or other urinary tract problems, family health history, and sexual history. You and your doctor will discuss your general health and the results of previous testing. For women, your doctor will: Evaluate the possibility of. Testicular exam and testicular self-exam are two ways to find lumps or other problems in the testicles. The two testicles, or testes, are the male sex organs. They are located in the scrotum, a pouch below the penis. The testicles make sperm and the male hormone testosterone. Each testicle is about the size and shape of a small egg

A: Normal exam or pertinent findings. P: 1) Diagnostic (lab, x-ray, EKG, other) that you plan for this patient. 2) Treatment 3) Education 4) Consultation, Collaboration or Referral 5) Follow-up Breast Exam Documentation Normal Exam: Size (if remarkable). Symmetric. Nipples (number, placement, inversion, discharge) Genitourinary- She denies dysuria, heavy bleeding and incontinence. Date of LMP was 1 week ago. Had first period at age 14, has had regular monlthy periods. Admits to sexual conduct with only one partner. 8. Musculoskeletal- Patient denies joint pain, swelling, muscle pain or cramps, neck pain or stiffness, changes in ROM. 9 Study Exam 1 - Starting the Physical Examination: General Survey and Vital Signs flashcards from Olivia Weiss's class online, or in Brainscape's iPhone or Android app. Learn faster with spaced repetition

The Tanner scale (also known as the Tanner stages or Sexual Maturity Rating (SMR)) is a scale of physical development in children, adolescents and adults.The scale defines physical measurements of development based on external primary and secondary sex characteristics, such as the size of the breasts, genitals, testicular volume and development of pubic hair Sample Normal Exam Documentation: Documentation of a basic, normal abdominal exam should look something along the lines of the following: Abdomen is soft, symmetric, and non-tender without distention. There are no visible lesions or scars. The aorta is midline without bruit or visible pulsation. Umbilicus is midline without herniation Examination of abdomen with notation of presence of masses or tenderness. Examination for presence or absence of hernia. Examination of liver and spleen. Obtain stool sample for occult blood test when indicated. Genitourinary. FEMALE: Includes at least seven of the following eleven elements identified by bullets Examination? Growth measurements correlate directly to nutritional status and can indicate whether a child's health and well-being are at risk.1 Deviations from normal growth patterns may be familial patterns but may indicate medical problems.2 For example, abnormal linear growth or poor weight gain could indicate a variet

Normal Physical Exam Template Samples - MT Sample Report

  1. ation Lessons, Guidelines with Text, Images, Videos/Movies & Audio/Sound. PULMONARY EXAM (QUICKTIME & WINDOWS MEDIA PLAYER) - Geisel School of Medicine, Dartmouth College Multimedia Pulmonary Exam Videos, Chest Exa
  2. ASSESSING THE MALE GENITOURINARY SYSTEM Outcomes Identify pertinent male genitourinary history questions. Obtain a male genitourinary history. Perform a male genitourinary physical assessment. (Continued) Outcomes Document pertinent male genitourinary assessment findings. Identify actual/potential health problems stated as nursing diagnosis
  3. al dribbling
  4. Evaluation and Management (E/M) Patient Examples 99214 Office visit for a 13-year-old male, established patient, with depression, anxiety, and anger outbursts. Office visit for a 70-year-old male, established patient, with stable depression and recent mild forgetfulness. RY CC 13-year-old male seen for follow up visit for mood and behavior.
  5. ation Constitutional • Exa

All templates, autotexts, procedure notes, and other documents on these pages are intended as examples only. Your documentation in the medical record should always reflect precisely your specific interaction with an individual patient. Merely copying and pasting a prewritten note into a patient's chart is unethical, unsafe, and possibly. Male Urogenital Teaching Associates (MUTAs) are men who utilize their bodies as teaching tools in the instruction of well man urogenital exam techniques. Sessions take place in your facility or other available space. One MUTA session consists of a 4:1 student to instructor ratio and runs about one and a half hours to one hour 45 minutes Exam: Male. Undescended Testes ( Cryptorchidism) More common in Premature Infant s. Retractile Testes that can be milked into Scrotum do not require additional evaluation (only routine follow-up) Communicating Hydrocele. Processus vaginalis fails to close allowing free passage of peritoneal fluid into Scrotum

A Guide to the Clinical Male Urogenital Examinatio

Management Services: Exam Determining the Level of Exam An E/M service's exam component is, as the name implies, the physician's physical examination of the patient. This is the most significant difference between the 1995 and 1997 Documentation Guidelines for Evaluation and Management Services. The 1995 and 1997 Guidelines defin Genitourinary Musculoskeletal Skin Neurologic Psychiatric Heme/Lymph/Immun Exam-1995 DGs There are four types of exam: •Problem focused- a limited exam of the affected body area or organ system •Expanded Problem Focused- A limited exam of the affected area and other related organ system 1 Head-to-toe Nursing Assessment. A comprehensive guide to head-to-toe assessment for nurses, this 37-minute instructional video explains the practical way of doing complete physical assessment for nurses. The step-by-step instructions are clearly explained by a nursing instructor from Northwest Iowa Community College. YouTube

Male GU Exam - American Urological Associatio

example, in a specialized primary care clinic such as an STD or family planning clinic, the 1997 Single Organ System Guidelines for Genitourinary Examination may be more applicable. Components and Elements Required for Documentation for E&M Visits The components and elements that must be documented for each E&M visit are presented i MALE AND FEMALE GENITALIA, FEMORAL PULSE ASSESSMENT. GENITOURINARY(GU) ASSESSMENT: URINE AND STOOLS. Unfasten the diaper. Always cover the penis with the diaper or you may be surprised with a shower. Female Genitalia. The clitoris is usually edemetous. The labia majora usually covers the labia minora. In premature infants, the labia minora is. GU/ PELVIC: Urethral meatus normal without discharge or irritation. External genitalia: no lesions noted, vaginal walls pink, pubic hair, scant, shaven. Vagina: Mucosa moist and slightly reddened. Small amount of thick, tan, odorous discharge noted. Cervix: pink, w/o lesion or mass. Bimanual exam: lowe Genital Exam - Male (Pre- or Early Puberty) Genital Exam - Male (Pre- or Early Puberty) An exam of your child's genitals (JEN-ah-tuls) is done to check for possible disease, injury or abnormality. A parent may stay in the room during the exam if the child does not mind (Picture 1)

Annual GYN Exam Medical Transcription Sample Report

these templates are for Pis and their study coordinators and should be used as examples or templates to build from and modify to meet their specific needs. Source document templates include inclusion/exclusion worksheet, adverse event tracking log, medications log, missed visit, early withdrawal form, study visit form, randomization form, study procedures form, physical evaluation form. This is an example of a head-to-toe narrative assessment note. I have my first-semester nursing students start by writing out a narrative assessment on the clinical floor, before proceeding to any facility assessment flowcharts.Quote10/05/2009 0800.86 y.o. male admitted 10/01/09 for left-sided cv.. The provider should endeavor to individualize the consultation and examination style so that it meets the needs of the patient. 12, 13. Patient Positioning. The pelvic examination is usually performed with the patient lying supine on an office examination table with the knees flexed, and with the feet in supporting stirrups Complete Head-to-Toe Physical Assessment Cheat Sheet. Nursing assessment is an important step of the whole nursing process. Assessment can be called the base or foundation of the nursing process. With a weak or incorrect assessment, nurses can create an incorrect nursing diagnosis and plans therefore creating wrong interventions and.

Introduction Physical examination should be relevant to the anatomy that is present, regardless of gender presentation, and without assumptions as to anatomy or identity. Sensitive history taking is required to understand the myriad and individualized changes and characteristics in the context of hormone administration and surgical intervention We point out that, in the rarecircumstances in which a teenage male gets cancer, testicularcancer is the most likely possibility, and only a thorough genitalexam can pick this up at an early, treatable stage. We do the examination with a chaperone present--a nurse, nurse'saide, medical student, or any clinician who is available at thetime Male victims of sexual violence should be triaged in the same manner as female victims. The same procedures for obtaining consent, taking a history, conducting the physical examination (although the genital examination will be different) and ordering diagnostic laboratory tests should be followed, that is

3. Assessment of male reproductive function begins with an evaluation of urinary function and symptoms. This assessment includes a focus an sexual function as well as manifestations of sexual dysfunction. 4. The patient is asked about his usual state of health and any recent change in general, physical and sexual activity On the CPC exam, you'll be tested on your knowledge of the male and female genital systems.You'll want to be familiar with both the structure of these systems and the procedures performed on them. The majority of these procedures are surgical in nature, so we'd find them in the Surgery section of the CPT manual.. Procedure codes for the male genital system, reproductive system and.

MyDevelopmentLab Video Serie

Performing a Genital Examination This chapter provides the information that service providers need to correctly perform a genital examination on a male client. It explores what providers must do before perform-ing a genital examination, including setting up the examination area and preparing the client psychologically and physically Examination (E) - Objective information Extent of PFSH, ROS and physical exam performed • NEVER DOCUMENT PATIENT HERE FOR FOLLOW-UP WITHOUT •Genitourinary (Female) (Male) •Respiratory •Hematologic / Lymphatic / Immunologic •General Multi-system Exam 21. • OR a GU physical exam notation to indicate cervix is not present. eye exam. At a minimum, documentation in the medical record must include one of the following: Female and male adolescents who completed an HPV vaccine series by the 13th birthday. (Two-or three-dos

PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE Page 2 of 39 Adapted from the Kentucky Public Health Practice Reference, 2008 and Jarvis, C, (2011). Physical examination th& health assessment. (6 Eds). Elsevier: St. Louis.MO. by Wright State University on May 28, 2012 for the NLN Assessment Exam for Credit by Exam Test Out 5 SKIN: Warm, well perfused. No skin rashes or abnormal lesions. MSK: No deformities or signs of scoliosis. Normal gait. EXT: No clubbing, cyanosis, or edema. NEURO: Ambulating with no limitations. Normal muscle strength and tone. No focal deficits A comprehensive pelvic exam includes assessment of the external genitalia-which will be discussed in this video, followed by examination of the vagina and cervix with a speculum-to be covered in the video titled Pelvic Exam Part II; and a bimanual evaluation of the pelvic organs-reviewed in Part III of this series The male rectal exam remains an important part of the physical exam, particularly for patients with abdominal, genitourinary, or gastrointestinal concerns. It is a sensitive procedure and requires careful attention to verbal and body language to ensure patient comfort 9. Genitourinary (male) 10.Genitourinary (female) 11. Lymphatic 12. Musculoskeletal 13. Skin 14. Neurologic 15. Psychiatric Physical Exam Bullets Constitutional 1) Three vital signs 2) General appearance Eyes 1) Inspection of conjunctivae and lids 2) Examination of pupils and irises (PERRLA