Documentation of rectal examination performance in the clinical teaching unit of a university hospital

Digital rectal examination is used to evaluate the distal rectum and other organs, including the prostate gland. It may be combined with fecal screeni ng for occult blood loss, and annual performance has been recommended for a symptomatic individuals over age 40 years for cancer screening. In this stu dy, documentation of digital rectal examinations was assessed through a rev iew of hospital medical records of a randomly selected group of 100 patient discharges (55 females and 45 males) from a total of 896 patients admitted through a hospital emergency room to a medical clinical teaching inpatient unit of a university hospital during a six-month period. In this group, 26 % were admitted for a gastrointestinal disorder, but only 17% of all hospit alized patients had rectal examinations done by the medical resident house staff and/or attending medical staff directly responsible for the care of t hese patients. Occult blood testing was done in 15 patients. Pelvic and bre ast examinations were rarely documented. The majority of rectal examination s (ie, 13 of 17) were 'same sex' examinations, appeared to be used largely for testing or confirmation of grossly visible blood loss and were never co nfirmed by attending staff. The presence or absence of nursing staff during examinations was not documented. The prostate examination was normal in on e patient but not documented in the other 44 males (ie, 26 patients over ag e 60 years). In conclusion, rectal examinations (as well as breast and pelv ic examinations) were rarely documented in the medical teaching unit by med ical resident house staff or their attending staff.