General Section
SKILLED DOCUMENTATION GUIDELINES — EXPANDED
DiraChart · Clinical Reference · Read-only baseline inherited by all agencies
Body System Reference · 2.38
Female Reproductive
The adult female genitourinary system (non-obstetric), assessed clinically and with dignity. Routed here: vaginal and pelvic findings, postmenopausal bleeding, post-operative gynecologic care, and pelvic-floor and prolapse management. The bladder, urinary catheter, and urinary infection are documented in Urinary/Renal; the vulvar and perineal skin exam is documented in External Genitalia. Obstetric and perinatal care is a separate build and is not covered here. This is a clinical assessment performed with the patient’s consent and privacy and a chaperone per agency policy.
Module code | SYS-FEMALE-REPRO |
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Version | 1.0 · Population: Adult · Authoring level: DiraChart (read-only baseline; agencies may append) |
Used alongside | Urinary / Renal (bladder, catheter, infection) · External Genitalia (vulvar / perineal skin) · Lines / Drains / Devices (surgical drains) · Vital Signs |
How to use this module This module supplies the clinical adult female genitourinary assessment (non-obstetric) — vaginal and pelvic status, postmenopausal bleeding, post-operative gynecologic care, and pelvic-floor and pessary management — and the skilled language that proves the care took a licensed nurse. The assessment is medically necessary (post-operative recovery, bleeding evaluation, prolapse and pessary care, infection recognition) and is always performed professionally, with the patient’s consent and privacy protected and a chaperone present per agency policy. The bladder and catheter are documented in Urinary/Renal and the vulvar skin in External Genitalia; obstetric care is a separate build. Each narrative is a structured example to edit to the actual visit and the patient’s orders — not a phrase to copy. |
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