Use when voiding and post-operative recovery are on track and there is no acute finding. 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 male genitourinary assessment completed with the patient’s consent and privacy and a chaperone present per policy. Voiding at baseline for [prostatic status]; [no] suprapubic distension; post-void residual [value] within the expected range where measured. Scrotum and testes without acute pain, new mass, or significant swelling; [chronic finding unchanged]. No new or incarcerated inguinal hernia. [Post-operative site/catheter healing/functioning without bleeding, infection, or obstruction.] Genital and perineal skin intact (see External Genitalia). The assessment against baseline confirms stable voiding and recovery and no acute scrotal, hernia, or infection finding, and continued appropriateness of the plan; catheter or post-operative care and the warning signs to report were reinforced with the patient/caregiver, who [teach-back result] (cross-reference Urinary/Renal).
Short form
Skilled male GU assessment (consent, privacy, chaperone per policy): voiding at baseline, no distension, PVR within range; scrotum/testes without acute pain or new mass; no incarcerated hernia; [post-op site/catheter healing]; skin intact. Plan continued. Catheter/post-op teaching reinforced, teach-back correct (see Urinary/Renal).
