Normal Pelvic Exam Documentation
Find the essential components of a standard normal pelvic exam and see how our AI medical scribe turns your live encounter into a structured draft.
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For OB/GYNs and Primary Care
Clinicians who perform routine pelvic exams and need consistent, high-fidelity documentation.
Standardized Findings
Get a clear breakdown of what constitutes a 'normal' exam across all three phases of the pelvic assessment.
From Encounter to Note
Move from a live patient recording to a reviewable, EHR-ready draft without manual typing.
See how Aduvera turns a recorded visit into a transcript-backed draft you can review before charting around normal pelvic exam documentation.
High-Fidelity Documentation for Pelvic Exams
Ensure no part of the exam is omitted while maintaining a strict review process.
Phase-Specific Structuring
The AI separates findings into external genitalia, speculum exam (cervix/vaginal walls), and bimanual palpation.
Transcript-Backed Citations
Click any part of the generated pelvic exam note to see the exact source context from the encounter recording.
EHR-Ready Output
Generate a clean, structured summary of normal findings that you can copy and paste directly into your EHR.
Draft Your Pelvic Exam Notes
Transition from the exam room to a finalized note in three steps.
Record the Encounter
Use the web app to record the patient visit, including your verbal findings during the exam.
Review the AI Draft
Verify that the AI correctly captured the normal status of the cervix, uterus, and adnexa.
Finalize and Paste
Adjust any specific nuances and copy the structured note into the patient's medical record.
Standards for Normal Pelvic Exam Documentation
A complete normal pelvic exam note should explicitly document three distinct stages: the external exam (no lesions, normal distribution of hair, no discharge), the speculum exam (vaginal mucosa pink and moist, cervix pink, smooth, and closed without discharge), and the bimanual exam (uterus midline, non-tender, and mobile; no adnexal masses or tenderness). Omitting any of these three sections can lead to ambiguity regarding which parts of the exam were actually performed.
Using an AI medical scribe eliminates the need to recall these specific descriptors from memory at the end of a shift. By recording the encounter, the AI captures the clinician's real-time observations and organizes them into these standard categories. This allows the clinician to focus on the review and verification of the findings—checking citations against the transcript—rather than drafting repetitive 'normal' descriptions from scratch.
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Common Questions
Transcript-backed documentation, clinician review, and EHR-ready note output are built into every workflow.
Can I use a specific 'normal' template for pelvic exams in the app?
Yes, the AI generates structured notes based on the encounter, and you can review them against your preferred style, such as SOAP or H&P.
How does the AI handle the bimanual exam portion of the note?
It identifies mentions of uterine position, mobility, and the absence of adnexal masses to draft the bimanual section of the documentation.
What happens if the exam is normal except for one finding?
The AI captures the specific abnormality mentioned during the encounter while maintaining the 'normal' status for the remaining components.
Can I turn a recorded pelvic exam into a draft immediately?
Yes, once the encounter is recorded, the AI generates a structured draft that you can review and copy into your EHR.
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.