General Section
SKILLED DOCUMENTATION GUIDELINES — EXPANDED
DiraChart · Clinical Reference · Read-only baseline inherited by all agencies
Body System Reference · 2.37
Male Reproductive
The adult male genitourinary system, assessed clinically and with dignity. Routed here: benign prostatic hyperplasia and urinary retention, scrotal and testicular findings, and post-operative urologic care. The bladder, urinary catheter, and urinary infection are documented in Urinary/Renal; the perineal and genital skin exam is documented in External Genitalia; an inguinal-hernia or perineal-skin emergency is cross-referenced there. This is a clinical assessment performed with the patient’s consent and privacy and a chaperone per agency policy.
Module code | SYS-MALE-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 (perineal / genital skin) · Lines / Drains / Devices (urologic drains) · Vital Signs |
How to use this module This module supplies the clinical adult male genitourinary assessment — prostatic and voiding status, the scrotal and testicular exam, and post-operative urologic care — and the skilled language that proves the care took a licensed nurse. The assessment is medically necessary (catheter care, post-operative recovery, retention, infection and complication 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 genital skin in External Genitalia. 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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