Documentation of a Negative Physical Breast Exam
A negative clinical breast examination should be documented as "Normal/Negative: No abnormalities on visual inspection or palpation," and must include descriptive findings that establish a baseline for future comparison. 1
Essential Documentation Framework
Interpretation Statement
- Document the exam as "Normal/Negative" when no abnormalities are found on visual inspection or palpation 1
- This interpretation indicates no asymmetrical findings that warrant further evaluation 1
Required Descriptive Elements
Even when the exam is negative, reporting should include a description of findings in specific and precise language to provide a baseline for interpreting future results from visual inspection and palpation 1. The documentation should follow the examination sequence:
Visual Inspection Findings
- Document skin appearance (no erythema, dimpling, or peau d'orange) 1
- Note nipple characteristics (no excoriation, scaling, or eczema) 1
- Record breast contour and symmetry 1
Palpation Findings
- Document tissue characteristics including density and nodularity patterns 1
- Note that no discrete masses were identified 1
- Record examination of tissue at three pressure levels (subcutaneous, mid-level, and down to chest wall) 1
- Document that tissue beneath the nipple was palpated (not squeezed) 1
- Confirm examination of upper outer quadrant and subareolar tissue, as these are the most common sites for cancer 1
Lymph Node Assessment
- Document examination of axillary, supraclavicular, and internal mammary nodal basins 1
- Note absence of palpable lymphadenopathy 1
Standardized Reporting Format
Develop a consistent, standardized lexicon of terms and format for documenting CBE findings 1. Electronic reporting should be encouraged for compatibility with medical records systems 1.
Follow-Up Documentation
- For a normal/negative CBE, document that repeat CBE at the next screening interval or preventive health examination is the appropriate follow-up 1
- The descriptive findings from this normal/negative CBE should serve as the baseline for the next interval examination 1
Critical Documentation Pitfalls to Avoid
- Never document simply "breast exam normal" without descriptive details, as this provides no baseline for future comparison 1
- Avoid vague terminology; use specific descriptors for tissue characteristics 1
- Do not omit documentation of nodal basin examination 1
- Ensure documentation reflects examination of both breasts in both upright and supine positions 1