How do you document a digital rectal exam (DRE) on a patient with altered mental status?

From the Guidelines

To document a digital rectal exam (DRE) on a patient with altered mental status, it is crucial to prioritize thorough and objective documentation, including the clinical indication, patient positioning, and specific findings such as anal tone, masses, stool characteristics, and prostate assessment if applicable, as supported by the principles outlined in the american gastroenterological association medical position statement on constipation 1.

When performing a DRE on a patient with altered mental status, several key points must be considered to ensure that the documentation is comprehensive and meets both clinical and medicolegal standards.

• The clinical indication for the DRE should be clearly documented, whether it be for evaluating constipation, as discussed in the american gastroenterological association medical position statement on constipation 1, or for other reasons such as GI bleeding or prostate assessment.
• The patient's altered mental status and their inability to provide consent should be noted, with an explanation that the exam was performed due to medical necessity.
• Details about the patient's positioning during the exam, typically the left lateral decubitus position, should be included, as this position is often used for rectal exams to facilitate the examination process.
• Findings from the exam should be thoroughly documented, including:
  • Anal tone and any abnormalities
  • Presence of masses or other abnormalities
  • Stool characteristics, such as color, consistency, and the presence of blood
  • Prostate findings if the prostate was assessed, including size, consistency, and tenderness
  • Any response from the patient during the procedure, which can be relevant even in patients with altered mental status
• It should also be noted if a chaperone was present during the exam, as this is an important aspect of maintaining patient dignity and safety.

The importance of objective and thorough documentation cannot be overstated, especially in patients who are unable to communicate their symptoms or provide detailed histories due to altered mental status. This documentation not only guides clinical care and follow-up but also serves as a legal record of the events surrounding the patient's treatment. By following these guidelines and prioritizing comprehensive documentation, healthcare providers can ensure that patients receive appropriate care while also protecting themselves and their institutions from potential legal issues.

From the Research

Documenting Digital Rectal Exam on an Altered Patient

To document a digital rectal exam (DRE) on a patient with altered mental status, consider the following points:

• The DRE is a crucial component of the physical examination, especially in trauma patients or those with abdominal pain 2, 3, 4.
• However, the utility of the DRE in patients with altered mental status may be limited, as the patient may not be able to provide accurate feedback or cooperate fully with the examination.
• When documenting the DRE, note the presence or absence of gross blood, the results of the Hemoccult test, the prostatic examination, rectal vault integrity, and rectal sphincter tone 2.
• The DRE may be more useful in patients with specific conditions, such as penetrating injuries to the perineal/pelvic area, questionable spinal cord damage, or severe pelvic fractures with potential urethral disruption or open fractures in continuity with the rectal vault 2.
• The accuracy of the DRE may be affected by the patient's altered mental status, and the results should be interpreted with caution.

Key Considerations

• The DRE has poor sensitivity for detecting spinal cord, bowel, rectal, bony pelvis, and urethral injuries in trauma patients 4.
• The DRE may not be useful in patients with undifferentiated abdominal pain, and its use should be highly selective 3.
• Documentation of the DRE is essential, but it may be rarely documented in medical records, especially in patients with altered mental status 5.
• Teaching medical students how to perform a DRE is crucial, and the use of rectal teaching associates (RTAs) may be an effective method for increasing skills and confidence in the procedure 6.

Documentation Tips

• Document the DRE findings clearly and concisely, including any abnormal results or concerns.
• Note the patient's cooperation and ability to provide feedback during the examination.
• Consider the patient's altered mental status when interpreting the results of the DRE and documenting the findings.
• Use standardized documentation templates or forms to ensure consistency and completeness of the documentation.