Pelvic Exam Positioning Checklist Form
Complete this checklist to ensure proper patient preparation and positioning for a pelvic exam.
Patient identity verified (using two identifiers, e.g., name and date of birth)
*
Yes
No
Patient privacy ensured (door closed, privacy curtain in place)
*
Yes
No
All necessary supplies available (gloves, speculum, lubricant, drapes, etc.)
*
Gloves
Speculum
Lubricant
Drapes
Other
Procedure explained to patient
*
Yes
No
Patient given opportunity to ask questions
*
Yes
No
Patient appropriately draped for exam
*
Yes
No
Patient positioned at end of exam table with feet in stirrups
*
Yes
No
Lower extremities properly supported and hips flexed
*
Yes
No
Exam table height and lighting adjusted for procedure
*
Yes
No
Staff member completing checklist (name/initials)
*
Submit Checklist
Should be Empty: