Compliance Department
ELEMENTS OF
GENITOURINARY
EXAMINATION
11/2010
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Elements of Genitourinary Examination: A Comprehensive Guide, Study notes of Nutrition
The essential elements of a genitourinary examination, including vital signs assessment, inspection and palpation of various body areas, and lymphatic and neurological assessments. The guide covers both male and female examinations and provides documentation requirements.
What you will learn
- What documentation requirements are associated with a genitourinary examination?
- What are the vital signs that should be measured during a genitourinary examination?
- What elements should be inspected and palpated during a female genitourinary examination?
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Compliance Department
ELEMENTS OF
GENITOURINARY
EXAMINATION
Elements of Genitourinary Examination
System/ Body
Area
Elements of Examination
Genitourinary
Constitutional
•^
Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3)pulse rate and regularity, 4) respiration, 5) temperature, 6) height,7) weight (May be measured and recorded by ancillary staff) •^
General appearance of patient (e.g., development, nutrition, body habitus, deformities, attention to grooming)
Neck
- Examination of neck (e.g., masses, overall appearance ,symmetry,tracheal position, crepitus) •^
Examination of thyroid (e.g., enlargement, tenderness, mass)
Respiratory
- Assessment of respiratory effort (e.g., intercostal retractions, use ofaccessory muscles, diaphragmatic movement) •^
Auscultation of lungs (e.g., breath sounds, adventitious sounds, rubs)
Elements of Genitourinary Examination
System/ Body
Area
Elements of Examination
Genitourinary
Genitourinary
MALE: • Inspection of anus and perineum Examination (with or without specimen collection for smears andcultures) of genitalia including: •^
Scrotum (e.g., lesions, cysts, rashes)
-^
Epididymides (e.g., size, symmetry, masses)
-^
Testes (e.g., size, symmetry, masses)
-^
Urethral meatus (e.g., size, location, lesions, discharge)
-^
Penis (e.g., lesions, presence or absence of foreskin, foreskin retractability, plaque, masses, scarring, deformities Digital rectal examination including: •^
Prostate gland (e.g., size, symmetry, nodularity, tenderness)
-^
Seminal vesicles (e.g., symmetry, tenderness, masses, enlargement) •^
Sphincter tone, presence of hemorrhoids, rectal masses
Elements of Genitourinary Examination
System/ Body
Area
Elements of Examination
Genitourinary
Genitourinary (Continued)
FEMALE: Includes at least seven of the following eleven elements identified bybullets: •^
Inspection and palpation of breasts (e.g., masses or lumps, tenderness, symmetry, nipple discharge) •^
Digital rectal examination including sphincter tone, presence of hemorrhoids, rectal masses Pelvic examination (with or without specimen collection for smearsand cultures) including: •^
External genitalia (e.g., general appearance, hair distribution, lesions) •^
Urethral meatus (e.g., size, location, lesions, prolapse)
-^
Bladder (e.g., fullness, masses, tenderness)
-^
Vagina (e.g., general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele)
Elements of Genitourinary Examination
Content and Documentation Requirements
Level of Exam
Perform and Document:
Problem Focused
One to five
elements identified by a bullet.
Expanded Problem Focused
At least six
elements identified by a bullet.
Detail
At least twelve
elements identified by a bullet.
Comprehensive
Perform
all
elements identified by a bullet; document
every element in an
Underlined/bold
box and at least
one element in a non-underlined/bold box.
Resources
UCLA Compliance Office
Marti Arvin, Chief Compliance Officer(310) 794-
- Confidential Hotline 1-800 296-7188 • UCLA Compliance Website
http://www.mednet.ucla.edu/compliance/
.