IMA WELL WOMEN’S CLINIC
TO REVIEW GUIDELINES FOR ABNORMAL RESULTS: ASCCP.ORG
PROGRESS NOTE TEMPLATE: (UNDER STHE STACKED BOXES ICON) MS OBGYN FEMALE-PREVENTATIVE VISIT
PAP SMEAR ORDER: CYTOLOGY, GYN (ALSO COMES UP WITH “PAP SMEAR”)
• PICK CYTOLOGY (AND REFLEX HPV WILL AUTO-SELECT) OR CYTOLOGY WITH HPV (DEPENDING ON AGE)
• BRUSH: GREEN ¼ TO ½ TURN INSIDE THE OS SWIRL 10X ALONG THE WALLS OF THE VIAL AND TOSS
• BROOM: PURPLE 5 TURNS INSIDE THE OS GENTLY JAB 10 X ON THE FLOOR OF THE VIAL AND TOSS
BILLING LEVEL: LEVEL 4, ESTABLISHED (IF ATTENDING COMES IN)
BILLING DIAGNOSIS: TRY TO PUT A NON-Z CODE AS PRIMARY IF POSSIBLE (IF YOU DISCUSSED ANY SYMPTOMS), IF NOT, USE CERVICAL CANCER SCREENING ETC.
WHAT TO DO AT THE END OF THE VISIT:
• PAP VIAL: MAKE SURE ITS LABELED (MA/LPN PRINTS OUT LABELS AND PLACES THEM ON THE COUNTER BY THE MA STATION – THESE ARE PRINTED FOR YOU WITHOUT YOU HAVING TO ENTER ANY EPIC ORDERS)
• PLACE A LABEL IN THE PAP LOG BOOK IF YOU DID A PAP
• ORDER PAP IN EPIC – PLACE BOTH THE COPIES OF ORDERS THAT PRINT (4 SHEETS) IN THE ZIPLOC OUTER POCKET
• PLACE PAP VIAL IN THE ZIPLOC INNER POCKET
• PLACE THE STD VIAL IN THE ZIPLOC IF ANY STD TESTING DONE (HAND WRITE LAST NAME ON VIAL) – MA WILL LABEL THAT FOR YOU
• LEAVE ZIPLOCK IN LAB (1ST ROOM)