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Well-Woman Visit - ACOG

Patients Aged 21 Years and Older. The College guidelines recommend that a pelvic examination be performed on an annual basis in all patients aged 21 years and older (2). No evidence supports or refutes the annual pelvic examination or speculum and bimanual examination for the asymptomatic, low-risk patient.


Pelvic Exam Documentation - eXam Answers Search Engine

CPT Code 76856 Complete Pelvic Evaluation Per the American Urological Society, elements of a complete pelvic ultrasound (76856 Ultrasound, pelvic (nonobstetric), real time with image documentation; complete) go beyond examination of the ovaries, to include medically necessary examination with a description and measurement of the uterus and ...


Pelvic Exam Form - WHI

WHI Form 81 - Pelvic Exam Ver. 6.1 R:\DOCUMENT\FORMS\F1-199\F81V6_1.DOC 02/14/00 Pg. 2 of 2 9. PAP SMEARCervix: 0 Absent 12. 1 Present 0 No Yes, probably benign Yes, p ossibly malignant 9.1. Flush with vaginal vault 0 1 2 Yes, vaginal smear 9.2. Friable with contact 0 1 2 Yes, Pap smear 9.3. Surface lesion/ growth (other than


Pelvic Exams and Evaluations - mtnstopshiv.org

PELVIC EXAM TERMINOLOGY | To document findings, use terms from the FGGT and the pelvic exam case report forms y When the term from the case report form is more specific than the term from the FGGT, use the term from the case report form y Use routine QC/QA opportunities to help ensure consistency of terminology across staff and exams



Assessment of the gynecologic history and the pelvic examination is part of the assessment of female patients in many clinical contexts. Clinician familiarity with the gynecologic evaluation can help reduce anxiety for both patients and healthcare professionals [1]. The gynecologic history and physical examination in adult women are reviewed here.


Physical exam documentation - WikEM

Slit lamp exam Slit Lamp with Floricine Lids/lashes = nl Conjunctiva = cl Cornea = cl Anterior chamber = D/Q Iris = R/R Lens = cl No FB noted on extensive exam


Office Notes-Normal Female Exam Template - 1 (Medical ...

No guarding, rigidity or rebound tenderness is seen on exam. Murphy and McBurney sign is negative. There is no Rovsing, obturator or psoas sign present. No hepatosplenomegaly and no hernias are noted. RECTAL: Normal tone. No masses. Soft, brown stool in the vault. Guaiac negative.


11 Documentation Elements for Medicare's G0101 Screening

Per the Centers for Medicare & Medicaid Services’ (CMS) document entitled, Screening Pelvic Examinations, on the Medicare Learning Network, G0101 is payable when at least 7 of the following 11 elements are included and documented in the exam. Follow the G0101 documentation requirements listed below. Documentation Guidelines for G0101. 1.