Pelvic Exam Documentation Template
Learn the essential sections for a thorough pelvic exam note and use our AI medical scribe to draft your own from a real encounter.
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For OB/GYN and Primary Care
Designed for clinicians performing routine or diagnostic pelvic exams who need structured, high-fidelity notes.
Get a Standardized Structure
Find the specific components required for a complete pelvic exam, from external inspection to bimanual findings.
Turn Encounters into Drafts
Move from this template to a finished note by recording your next exam with Aduvera.
See how Aduvera turns a recorded visit into a transcript-backed draft when you want pelvic exam documentation template guidance without starting from scratch.
High-Fidelity Pelvic Exam Drafting
Ensure every finding is captured and verifiable without manual typing.
Anatomical Segment Citations
Review specific transcript segments for external genitalia, speculum findings, and bimanual palpation before finalizing.
Structured Exam Layouts
Automatically organize findings into standard clinical sections like External, Speculum, and Bimanual exams.
EHR-Ready Output
Generate a clean, structured pelvic exam note ready to be copied directly into your patient's chart.
From Template to Final Note
Stop starting from a blank page and use a recording-first workflow.
Record the Encounter
Use the web app to record the pelvic exam and patient discussion in real-time.
Review the AI Draft
Check the generated note against the transcript-backed source context to ensure accuracy of findings.
Finalize and Paste
Verify the structured output and copy the completed pelvic exam documentation into your EHR.
Structuring a Comprehensive Pelvic Exam Note
A strong pelvic exam note must clearly delineate between the external exam (vulva, perineum), the speculum exam (vaginal walls, cervix, discharge), and the bimanual exam (uterine size, position, adnexal masses or tenderness). Documentation should specifically note the presence or absence of lesions, the appearance of the cervix, and any cervical motion tenderness or palpable masses to ensure clinical clarity and continuity of care.
Using an AI scribe to draft these sections eliminates the need to recall specific descriptors from memory hours after the visit. By recording the encounter, Aduvera captures the clinician's real-time observations, allowing the provider to simply review the transcript-backed citations and verify the findings before the note is finalized and moved to the EHR.
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Pelvic Exam Documentation FAQs
Transcript-backed documentation, clinician review, and EHR-ready note output are built into every workflow.
What are the essential sections of a pelvic exam template?
A complete template should include external inspection, speculum examination, and bimanual palpation findings.
Can I use this specific pelvic exam structure in Aduvera?
Yes, Aduvera supports structured clinical notes and can draft your pelvic exam findings based on the recorded encounter.
How does the AI handle specific findings like cervical motion tenderness?
The AI drafts the finding based on your spoken words during the exam, which you then verify via transcript citations.
Does the app support different note styles for these exams?
Yes, you can organize your pelvic exam findings within common styles such as SOAP or H&P notes.
Reclaim your evenings from chart notes
Let Aduvera turn visit conversations into a cleaner first draft so you can review faster and finish documentation with less after-hours work.