How to Document Pelvic Health Like an Expert
Finally! Pelvic health documentation that actually reflects the complexity of what you do.
How to Document Pelvic Health
Like an Expert
Finally! Pelvic health documentation that actually reflects the complexity of what you do.
Pelvic health rehabilitation is nuanced, layered, and highly skilled. But too often, our documentation fails to reflect that complexity. Skilled
interventions get reduced to vague language. Clinical reasoning disappears into exercise lists. Highly specialized care becomes difficult to justify to payers.
The PelviEd Documentation Manual was created to solve that problem.
This manual teaches pelvic health clinicians how to document what they are already doing clinically in a way that clearly demonstrates medical necessity, skilled intervention, and functional impact.
It is designed as the perfect companion to the PelviEd Newbie to Knowledgeable Manual, translating pelvic health clinical reasoning into clear, defensible, audit-ready documentation examples.
What This Book Is (and What It’s Not)
This manual is documentation focused only.
It does not teach how to diagnose or treat pelvic conditions.
Instead, it shows you how to document the findings and treatments you may already be performing.
Inside, you’ll find real-world documentation examples for:
Subjective examination
Objective findings
Skilled treatment interventions
Assessment statements
Short-term and long-term goals
Billing justification language
Each chapter demonstrates how to connect impairments → function → medical necessity, helping your notes tell the full clinical story.
Why Pelvic Health Documentation Matters
Pelvic health care often involves:
bladder dysfunction
bowel disorders
pelvic pain
sexual dysfunction
hormonal influences
nervous system dysregulation
musculoskeletal and visceral contributors
Yet documentation frequently reduces this complexity to:
“Patient performed pelvic floor exercises. Education provided.”
This manual helps clinicians document pelvic care in a way that:
✔ Reflects true clinical reasoning
✔ Demonstrates skilled intervention
✔ Links impairments to functional impact
✔ Protects against audits and denials
✔ Communicates clearly with other providers
When documentation reflects the complexity of pelvic health conditions, it protects the integrity of our profession and the access our patients have to care.
What You’ll Find in Every Chapter
Each chapter follows a consistent structure so you can quickly reference and apply the language in your own notes.
Subjective Checklists
Key patient history questions to document for each condition.
Objective Documentation Examples
Clear examples of how to document clinical findings using observable, defensible language.
Treatment Documentation
Examples that demonstrate why therapist skill not generic exercise was required.
Assessment Statements
Examples that connect:
impairments → functional limitations → need for skilled care
Functional Goals
Medicare-compliant examples of:
Short-term goals (STGs)
Long-term goals (LTGs)
Billing Justification Language
Examples supporting skilled use of codes including:
97535 – Self-care / Home management
97530 – Therapeutic activity
97112 – Neuromuscular re-education
97140 – Manual therapy
Inside the Book
This documentation manual includes 25 chapters plus bonus content covering the most common pelvic health presentations.
Core Pelvic Health Documentation
Tone Matters: Stop Guessing, Start Palpating
Bladder Function, Education, and Retraining
Bowel Function, Education, and Retraining
How to Kegel (or Not Kegel)
Down Training Techniques
Hormonal and Vulvovaginal Conditions
External Genital Hygiene
Synthetic vs Bioidentical Overview
Local Hormone Treatment
Hormone Replacement Therapy (HRT)
Birth Control: A Win Worth Re-Examining
Vulvodynia and Vestibulodynia
Genitourinary Syndrome of Menopause (GSM)
Vulvar Skin Conditions
Pain and Complex Pelvic Disorders
Pain Science Education
Endometriosis
Interstitial Cystitis (IC)
Irritable Bowel Syndrome (IBS)
Prostatitis
Vaginismus and Dyspareunia
Oncology and Structural Conditions
Prostate Cancer
Pelvic Organ Prolapse
Life Stages and Sexual Health
Sexual Activity Across Pregnancy and the Postpartum Transition
Receptive Anal Intercourse Considerations
Orthopedic and Movement Integration
Orthopedic Considerations
Exercise Prescription
Bonus Chapters
Pudendal Neuralgia
Pelvic Venous Disorder
Who This Manual Is For
This documentation guide is ideal for:
Pelvic health physical therapists
Pelvic health occupational therapists
New pelvic therapists learning documentation standards
Experienced therapists who want stronger documentation language
Clinicians preparing for audits or insurance scrutiny
It is especially helpful for clinicians who want their notes to accurately reflect the skill level of pelvic health care.
The Perfect Companion to the PelviEd Manual
The PelviEd Newbie to Knowledgeable Manual teaches the clinical framework.
The PelviEd Documentation Manual shows you how to document it.
Together they provide:
Clinical reasoning + documentation mastery
Instant Access
PelviEd Documentation Manual
✔ Digital download (PDF)
✔ 25 chapters + bonus content
✔ Ready-to-use documentation examples
✔ Designed for pelvic health clinicians
Price: $19.97
Dr. Tara Sullivan
PT, PRPC, WCS, IF
About the Author
Dr. Tara Sullivan, PT, PRPC, WCS, IF specializes in pelvic health and has dedicated her career to treating bowel, bladder, sexual dysfunctions, and pelvic pain. Driven by her mission to ensure no patient feels dismissed, helpless, or unseen, she empowers both patients and providers to find hope and healing through mentorship and clinical reasoning.
Because your pelvic health journey doesn’t start with more weekend courses. It starts with hope, mentorship, and mastering the basics!