Use when post-operative recovery is on track, there is no abnormal bleeding, and any prolapse or pessary is stable. Fill the bracketed blanks with the visit’s actual findings; the clinical findings are not changed — the reasoning a layperson cannot supply is added. The skilled rationale supports the record when it is accurate, individualized, consistent with the plan of care, and tied to the findings, orders, and patient response documented during the actual visit.
Skilled female genitourinary assessment completed with the patient’s consent and privacy and a chaperone present per policy. No abnormal vaginal bleeding, and specifically no postmenopausal bleeding; [no] pelvic pain. [Post-operative site/vaginal cuff healing without bleeding, infection, or dehiscence.] Prolapse/pelvic-floor status [unchanged, symptoms managed]; [pessary in place, comfortable, without erosion, retention, or abnormal discharge]. Vulvar and perineal skin intact (see External Genitalia); no infection signs. The assessment against baseline confirms healing recovery, no abnormal bleeding, and a stable prolapse or pessary, and continued appropriateness of the plan; post-operative or pessary care and the warning signs to report were reinforced with the patient/caregiver, who [teach-back result] (cross-reference Urinary/Renal).
Short form
Skilled female GU assessment (consent, privacy, chaperone per policy): no abnormal or postmenopausal bleeding; no pelvic pain; [post-op site healing]; prolapse/pessary stable; skin intact. Plan continued. Post-op/pessary teaching reinforced, teach-back correct (see Urinary/Renal).
