To standardize the documentation process for cervical cancer screenings, ensuring that all relevant patient information is accurately recorded and easily accessible. By following this SOP, healthcare providers can ensure that patients receive timely and appropriate care, facilitate continuity of care, and support data collection for quality improvement initiatives. This SOP also aims to streamline workflows and reduce the risk of errors in patient records.
Follow the step for documenting Cervical Cancer Screening service in Outpatient:
Log in Outpatient.
Search for the patient file. You can search for the patient file using any of the following methods:
Visits - This shows you a list of all visits for the day. If patients are not checked out in the system, the visit automatically gets checked out after 24 hours.
All Visits - Here you can search for patients using Phone number or Evax ID only. It shows you patient visit history.
Recent Activity - This shows you a list of files that you have recently opened and the time you accessed the file.
Go to the visit screen and click the plus icon on services to add a Cervical Cancer Screening service.
BACKGROUND TAB
Screening Background Section
Last Screened - Enter date when patient was last screened.
Last Screen Facility - Enter the facility where the patient last did her screening.
Last Screening Result - Enter results patient got on her last screening.
Facility Referred By - This only applies if VIP was actually sent from another facility.
Complaints - Enter if patient has any complaints since last screening.
Obstetrics History Section
Total Pregnancies (Gravida) - Enter total number pregnancies patient had.
Pregnancies carried to 6 months or later (Para) - Enter number of pregnancies that exceeded 6 months
Last Delivery Date - Enter the last date patient delivered.
Desires More Children - Select options if patients still desires more children or not.
Menstruation Onset - Enter the date patient started her mensuration periods.
LNMP - Enter the date when last month of menstruation period.
Ever Treated STI - If patient has ever tested for STIs select else then enter the date they were tested. If not, select no.
Post Menopausal - If patient is on menopause, select Yes then specify number of years. If not select No.
Referral Form Section
If patient brought a form from another facility, take a photo of the form and attach it here.
Pregnancy Test Section
If you click on test pregnancy it will create a pregnancy test lab order (GLU). The lab sample has to be drawn and sent to lab for tests and results. Once results are entered you will see them showing on this section.
SCREENING TAB
General Exam Section
Purpose for visit - Select the if patient is coming for the first time or rescreening.
First time screening – first cervical screening of their life.
Rescreening – this applies to any screening as long as its not their first time including those who screened in a different facility.
Active case follow up – must be used for cases where treatment is currently ongoing and monitoring progression i.e 6 weeks post procedure.
Screening Type - Select the screening type that is going to be done to the patient.
VIA – applies to all cervical screenings that include the use of Acetowhiting. (But does not include pap smear being done in the same sitting)
Exam only – applies specifically when an examination is being done to document findings without the need for acetowhite being used. (Can be used for post-procedure follow up for those above 50 as well since VIA doesn’t apply to them anymore.)
Pap smear – applies to cases where only pap smear is done with no other screening tools involved. Mostly used for VIPs who are 50 years and above.
Colposcopy and biopsy – applies to visual inspection with the purpose of doing a biopsy and actually doing the biopsy as well.
Colposcopy – Visual inspection without the need for biopsy due to other clinical interventions being planned.
VIA & Pap smear – applies to all cervical screenings that include the use of Acetowhiting and pap smear being done in the same sitting.
Enter the rest of the general exam questions according to your findings.
VIA - this only shows when you select VIA as screening type.
VIA Results options
Negative
Inconclusive – Concern pre-Cancerous lesion – this means clinician is not sure of the final result of the screening but has concerns therefore a PAP SMEAR or BIOPSY has been done for further investigations.
Suspicious for cancer – obvious mass seen
Inconclusive – This means screening is not complete, needs to re-screen to confirm result.
COLPOSCOPY TAB (this tab only shows when you select colposcopy as screening type)
Insert photo and enter notes for Green Filter, Lugo's and Acetic Acid.
Findings - Here you will enter all abnormalities observed and Result.
BIOPSY TAB (this tab only shows when you select colposcopy as screening type)
Consent - Patient has to consent and sign before the procedure.
PLAN TAB
In the management plan section, choose the option that fits your plan. Use the Plan Narrative option to elaborate on other aspects of your management plan for your VIP. For example, if you plan to provide STI treatment, use the narrative space to document additional plans such as prescribing antibiotics, counseling on the need for re-screening, and scheduling a follow-up review after two weeks.
NEXT APPOINTMENT
After you are done adding information on the service, add the next appointment the patient has to come for check up or another screening.
Add the date and of the next appointment and the service, and save.