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DOCUMENTATION: Documenting the Findings

Documenting the Physical Examination
line spacer The more detailed the description of the physical exam, the easier it will be in the future to testify about the results. Some healthcare facilities use standardized forms and/or anatomic diagrams. These may be used but should not take the place of a meticulously worded description of the physical examination findings.

When recording the physical exam, pay particular attention to the following:

  • Document both the presence and absence of physical findings.

  • Avoid using the term "Within Normal Limits (WNL)" because it does not adequately describe what portions of the exam were actually performed.

  • Describe the child/adolescent's demeanor factually, such as "patient crying" rather than "patient upset."

In the setting of a sexual abuse evaluation:

  • Record the Tanner stage. (For more information, see Oski's Pediatrics: Principles and Practice.)

  • Document the child's position during the examination (i.e., supine, frog leg, prone knee chest) and, in a female, the labial holding technique (separation or traction).

  • Describe findings related to female genitalia by using a clock face. In the supine position, the urethra is at 12 o'clock.

  • Avoid using terms that can be misinterpreted:

    • Never use the term "hymen intact." This has no universally understood meaning and supports the mistaken notion that the hymen is an all or none phenomenon, present in the absence of sexual abuse and absent after sexual abuse. The term "intact" implies untouched and should not be used in the medical record.

    • An "imperforate" hymen is an anatomically fused opening of the vagina which may be acquired from trauma or be a congenital finding. This terminology should be used to accurately reflect that hymen configuration and not be used to describe a poorly visualized opening.

    • Penetration, however slight, is considered penetration for purposes of the definition of sexual intercourse in penal law. The phrase "no evidence of penetration" should not be used in medical documentation.

    • Rape is a legal term and should not be used in the medical record.

    • The word "alleged" implies that you do not believe the victim and has a different legal meaning.

  • If a rape kit is completed:
    • Record the name of the person who received the kit once it was sealed.

    • Document the evidence that was collected in addition to the rape kit (e.g., clothing, photographs).

To address the possibility of neglect:

  • Document the current growth parameters (height, weight, and head circumference).
  • Provide previous growth parameter data, when available.
  • Describe the general appearance, including hygiene.

Documenting Laboratory Results and Imaging
line line When documenting laboratory results and imaging:
  • Note all diagnostic tests performed and the results, if available.
  • Record specific radiologic studies and the readings; if the readings are preliminary, document.
  • Record all cultures and the sites from which they were obtained.

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Documentation: Overview  Documentation: Documenting the History  Documentation: Documenting the Findings  Documentation: Documenting the Diagnosis  Documentation: Documenting Other Information  Documentation: Photographic Documentation  Documentation: Coding for Billing  Documentation: Additional Resources 

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Documenting the Physical Examination
Documenting Laboratory Results and Imaging