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Documentation : Documenting the Findings

Documenting the Physical Examination

Detailed descriptions of the physical exam are essential. Electronic medical records may be supported with standard forms and templates. Drawings using body diagrams may be uploaded, however, they should not take the place of a meticulously worded description of the physical examination findings.

When recording the physical exam, pay particular attention to the following:

  • Document both the presence and absence of physical findings.
  • Avoid using the term "Within Normal Limits (WNL)" and instead describe what portions of the exam were performed and the appearance.
  • Describe the child/adolescent's demeanor factually, such as "patient crying" rather than "patient upset." Avoid use of stigmatizing terms, such as patient “hysterical.” When a child refuses an examination, either the full examination or parts of the examination, document the patient’s request.

In the setting of a sexual abuse evaluation:

  • Record the Tanner stage. For information on Tanner Stages, see: https://www.brightfutures.org/wellchildcare/toolkit/maturity.html
  • Document the child's position during the examination (i.e., supine, frog leg, prone knee chest) and, in a female, the technique for examination of the labia (separation or traction).
  • Describe findings related to female genitalia by using a clock face. In the supine position, the urethra is at 12 o'clock.
  • Avoid using terms that can be misinterpreted:
    • Never use the term "hymen intact." This has no universally understood meaning and supports the mistaken notion that the hymen is an all or none phenomenon, present in the absence of sexual abuse and absent after sexual abuse. The term "intact" implies untouched and should not be used in the medical record.
    • An "imperforate" hymen is an anatomically fused opening of the vagina which may be acquired from trauma or be a congenital finding. This terminology should be used to accurately reflect that hymen configuration and not be used to describe a poorly visualized opening.
    • Penetration, however slight, is considered penetration for purposes of the definition of sexual intercourse in penal law. The phrase "no evidence of penetration" should not be used in medical documentation.
    • Rape is a legal term and should not be used in the medical record.
    • The word "alleged" implies that you do not believe the victim and has a different legal meaning.
  • If a rape kit is completed:
    • Record the names of all people who handle the rape kit, including the person who receives it for transport to the forensic laboratory.
    • Document the evidence that was collected in addition to the rape kit (e.g., clothing, photographs).

To address the possibility of neglect:

  • Document the current growth parameters (height, weight, and head circumference).
  • Provide previous growth parameter data, when available.
  • Describe the general appearance, including hygiene, use descriptions of areas of the body where there may be evidence of lack of regular grooming, such as dirt under nails, stool around the anal area, etc., and avoid writing a potentially stigmatizing phrase “poor hygiene.”


Consider organizing your EHR template to prompt the documentation of this data.

Documenting Laboratory Results and Imaging 

Laboratory results and imaging:

  • Note all diagnostic tests performed. Documentation of the results is typically input into the EHR and does not require re-documentation, except to indicate your interpretation and clinical reasoning as it pertains to your plan and next steps.
  • Record your review of radiologic studies and the readings and if you reviewed the radiographic findings with a radiologist.

Documentation