Examples of criteria for recording findings on the structured examination protocol
| Condition | Definition and rationale | Guidelines for recording observations |
|---|---|---|
| Adapted from Elias et al.5 | ||
| Vaginal discharge | The presence of vaginal secretions that are malodorous, excessive in amount, or yellow/green in colour. (This term is preferred to “vaginitis” or “vaginal infection” since the presence of observable discharge cannot be consistently correlated with either vaginal inflammation or infection.) | Record characteristics of vaginal secretions as follows: Odour: (a) normal, (b) malodorous Amount: (a) scanty, (b) normal, (c) profuse Colour: (a) clear, (b) white, (c) bloody, (d) yellow/green “Abnormal vaginal discharge” is present if results underlined are found or if there is a bloody discharge in a non-menstruating woman. |
| Pelvic tenderness | The presence of pain (as evidenced by changes in facial expression or muscle tone and/or bodily motion) during pelvic examination. (To minimise variation in the occurrence of mild discomfort or pain, this definition excludes pain verbally reported by the woman being examined unless it is accompanied by an observable reaction.) | Record the occurrence of pelvic tenderness as follows: Was pain experienced by the woman during bimanual examination? (a) No, (b) Yes |