How would you document a Digital Rectal Examination (DRE) on physical examination?

From the Guidelines

To document a Digital Rectal Examination (DRE) on physical examination, I would write a comprehensive note that includes all relevant findings, as recommended by the most recent and highest quality study 1. The documentation should begin with "Digital rectal examination performed with patient's consent in left lateral decubitus position." Then describe the external anal inspection findings, noting any external hemorrhoids, fissures, or skin tags. Document anal tone as normal, increased, or decreased. When examining the rectal vault, note any masses, tenderness, or nodularity. For male patients, describe the prostate gland size (small, normal, enlarged), consistency (soft, firm, hard), surface characteristics (smooth, nodular), presence of midline sulcus, and any tenderness, as suggested by 1 and 1. For female patients, note any palpable masses in the posterior vaginal wall. Document stool characteristics if present, including color and consistency, and whether a fecal occult blood test was performed with results. Conclude with any significant findings or absence thereof. This thorough documentation is essential for medical records, helps track changes over time, and provides valuable diagnostic information for conditions affecting the rectum, prostate, and surrounding structures, as emphasized by 1 and 1.

Some key points to consider when documenting a DRE include:

• Obtaining patient consent before performing the examination
• Describing the position of the patient during the examination
• Noting any abnormalities or significant findings
• Documenting the size, consistency, and surface characteristics of the prostate gland in male patients
• Recording any stool characteristics or results of a fecal occult blood test
• Concluding with any significant findings or absence thereof, as recommended by 1.

By following these guidelines and including all relevant findings, healthcare professionals can ensure that their documentation of a DRE is comprehensive and effective, as suggested by 1 and 1.

From the Research

Documenting a Digital Rectal Examination (DRE)

To document a DRE on physical examination, the following points should be considered:

• The procedure for DRE is outlined in various studies, including 2, which provides an overview of the potential findings from performing this test.
• The DRE is a key component in the early evaluation of patients with disorders of defecation, including constipation and fecal incontinence, as discussed in 3.
• When documenting a DRE, it is essential to note the presence of any abnormalities, such as suspicious nodules or irregularities, as these can be indicative of underlying conditions, such as prostate cancer, as mentioned in 4 and 5.
• The DRE findings should be interpreted in conjunction with other diagnostic tests, such as prostate-specific antigen (PSA) levels and magnetic resonance imaging (MRI), to provide a comprehensive assessment of the patient's condition, as discussed in 4 and 6.

Key Findings to Document

Some key findings to document during a DRE include:

• The presence of any palpable abnormalities, such as nodules or irregularities
• The size and location of any abnormalities
• The consistency and texture of the rectal wall and surrounding tissues
• The presence of any blood or other abnormalities in the stool
• The patient's level of discomfort or pain during the examination

Importance of Accurate Documentation

Accurate documentation of the DRE is crucial for:

• Providing a clear and comprehensive record of the patient's condition
• Informing treatment decisions and guiding further diagnostic testing
• Communicating findings to other healthcare professionals involved in the patient's care, as emphasized in 5 and 6.