documentation for assessments ?

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How do I document breast size? I have a final performance check off this week and I have a 1:3 chance that a breast exam will be part of it. I have been reviewing/studying, but I am unable to find the proper way to document size. Everything just states "note the breast size".

Specializes in CCU (Coronary Care); Clinical Research.

I personally don't think that you need to emphasize size so much as stating that "breasts equal in size bilaterally, no lumps or tender areas noted" or something to that effect. Note any drainage or anything significant that you notice. Remember to document teaching re: breast examination if done.


91 Posts

Thank-you, that makes perfect sense!

suzanne4, RN

26,410 Posts

The only reason size would come into play is if the patient had "quite large, pendulous breasts" ---- very hard to do adequte monthly breat exams because of size. Other than that, think of bras, an A cup is small, a B cup is average, C cup is now becoming the new average, and D cup is large. Maybe that will put it into better perspective for you.

Good luck on your exam............... :balloons:

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