tcfht-md06 pelvic examination revised - taddle...

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Last Updated 16-04-2014 by Rebekah Barrett, RN, MN Title: Pelvic Examination Number: TCFHT-MD06 Activation Date: 01-09-2011 Review Date: 14-04-2015 Sponsoring/Contact Person(s) (name, position, contact particulars): Alissia Valentinis, MD 790 Bay, Suite 522, Toronto, Ontario 416-591-1222 Order and/or Delegated Procedure: Appendix Attached: X No Yes Title: Pelvic Examination, including: Insertion of Vaginal Speculum Specimen Collection – cervical swabs, vaginal swabs, viral microbiology swabs, papanicolaou test Bimanual Exam if required Recipient Patients: Appendix Attached: No X Yes Title: Appendix A – Authorizer Approval Form Recipient patients must: Be active patients of a TCFHT primary care provider who has approved this directive by signing the Authorizer Approval Form Be female Meet the conditions identified in this directive Authorized Implementers: Appendix Attached: No X Yes Title: Appendix B – Implementer Approval Form Implementers must be TCFHT employed Regulated Health Care Providers or Physician Assistant (under the supervision of a physician). Implementers must complete the following preparation and sign the Implementer Approval Form: Assess own knowledge, skill, and judgment to competently perform pelvic examination (Note: this requires implementers to have the applicable added skills to place instrument, hand, or finger beyond the labia majora). Successfully complete the McMaster Clinical Skills in Well Women Workshop or equivalent hands-on training MEDICAL DIRECTIVE

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LastUpdated16-04-2014byRebekahBarrett,RN,MN

Title: PelvicExamination Number: TCFHT-MD06ActivationDate: 01-09-2011 ReviewDate: 14-04-2015Sponsoring/ContactPerson(s)(name,position,contactparticulars):

AlissiaValentinis,MD790Bay,Suite522,Toronto,Ontario416-591-1222

Orderand/orDelegatedProcedure: AppendixAttached:XNoYesTitle:

PelvicExamination,including:• InsertionofVaginalSpeculum• SpecimenCollection–cervicalswabs,vaginalswabs,viralmicrobiologyswabs,papanicolaoutest• BimanualExamifrequiredRecipientPatients: AppendixAttached:NoXYes

Title:AppendixA–AuthorizerApprovalFormRecipientpatientsmust:• BeactivepatientsofaTCFHTprimarycareproviderwhohasapprovedthisdirectivebysigning

theAuthorizerApprovalForm• Befemale• MeettheconditionsidentifiedinthisdirectiveAuthorizedImplementers:

AppendixAttached:NoXYesTitle:AppendixB–ImplementerApprovalForm

ImplementersmustbeTCFHTemployedRegulatedHealthCareProvidersorPhysicianAssistant(underthesupervisionofaphysician).ImplementersmustcompletethefollowingpreparationandsigntheImplementerApprovalForm:• Assessownknowledge,skill,andjudgmenttocompetentlyperformpelvicexamination(Note:

thisrequiresimplementerstohavetheapplicableaddedskillstoplaceinstrument,hand,orfingerbeyondthelabiamajora).

• SuccessfullycompletetheMcMasterClinicalSkillsinWellWomenWorkshoporequivalenthands-ontraining

MEDICALDIRECTIVE

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• Demonstrateabilitytocompetentlyperformpelvicexaminationduringsupervisionfromanauthorizingprimarycareprovideron3occasions

• ReviewFemaleReproductiveSystemPhysicalExamination&HealthAssessmentGuidelinesinanadvancedhealthassessmenttextbook(ex.Jarvis,2014orequivalentreference).

• Review“Thegynecologichistoryandpelvicexamination”inUptoDate,accessiblefromhttp://www.uptodate.com/contents/the-gynecologic-history-and-pelvic-examination?source=search_result&search=bimanual+exam&selectedTitle=1%7E150

• ReviewGammaDynacareSpecimenCollectionInformationforpaps,cervical,andvaginalswabs,accessiblefromhttp://www.gamma-dynacare.ca

• ReviewPublicHealthOntarioSpecimenCollectionguidelines,accessiblefromo http://www.publichealthontario.ca/en/ServicesAndTools/LaboratoryServices/Pages/Herpes_

simplex_Skin_genital.aspx-.U0WNNlwihg0o http://www.publichealthontario.ca/en/ServicesAndTools/LaboratoryServices/Pages/Kit

InstructionSheets/Virus-Culture.aspx-.U0WNm1wihg0• ReviewCanadianGuidelinesonSexuallyTransmittedInfections(PHAC,2013),accessiblefrom

http://www.phac-aspc.gc.ca/std-mts/sti-its/index-eng.php• ReviewOntarioCervicalScreeningCytologyGuidelinesSummary(CancerCareOntario,2012),

accessiblefromhttps://www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=13104Indications: AppendixAttached:XNoYes

Title:• Adultfemalepatientswhopresentforscreeningofcervicalcancer,sexuallytransmitted

infections,vaginaldischargeand/ordiscomfort,orcontraception.Contraindications:• Pediatric,pregnantpatients,orpatientswithpersonalhistoryofcomplexmedicalissuesshould

beseenbytheirprimarycareproviderConsiderations• Patientinformedofpurposes,risks,harms,andbenefitsoftesting,includingwhenresultswillbe

available,andpotentialfollowuprequirediftestispositiveornegative.• Patientabletogiveninformedconsentandiscooperativeanddoesnotneedrestraint.• Patientisinformedoftheimportanceofcontactnotificationintheeventofpositiveresults. Consent: AppendixAttached:XNoYes

Title:Patient’sconsentisimpliedforimplementertoperformexaminationifpatienthaspresentedtoclinicseekingtesting,andisaFamilyHealthTeampatient,whereinterprofessionalpracticeisexpected.GuidelinesforImplementingtheOrder/Procedure:

AppendixAttached:NoXYesTitle:AppendixC–SampleLabRequisitionAppendixD–SampleCytologyRequisition

Foreligibleandappropriatepatients,implementerperformsthefollowing:• Obtainsdetailedhistory(presentingsymptoms,dateoflastpaptestand/orswabsandresults,

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historyofSTIsorabnormalpaptests,sexualhistory,newpartners,LMP,contraception,vaginaldischargeordiscomfort)

• Provideseducationofwhattestingwillbedone,reviewequipment,whattoexpect,andallowtimeforquestions.

• Informspatientofpurposes,risks,harms,andbenefitsoftesting,includingwhenresultswillbeavailable,andpotentialfollowuprequirediftestispositiveornegative.

• Advisespatienttoemptybladderpriortopelvicexaminationfortheiraddedcomfort.• Allowspatienttoundressinprivate,providingcleanclinicalgarment.• Prepareslabrequisitionsformicrobiologyand/orcytologyusingthesupervisingprimarycare

providerinitialsinPracticeSolutions.• LabRequisitionsshouldbesignedasbelow:

o Signatureo ImplementerName/PrimaryCareProviderName(MedicalDirectiveTCFHT-MD06)

• Gathersandlabelsequipmentrequired(ex.gloves,speculum,lubricant,appropriateswabs,liquidbasedcytologycontainers,cytologybroomsandbrushes)

• Accordingtoclinicalpracticeguidelines,andmaintaininginfectioncontrolpracticeso Assessesexternalgenitaliao Assessesinternalgenitaliausingspeculumofappropriatesizeandshapeo Performsspecimencollectionaccordingtoguidelineso Performsbimanualexam,ifappropriate

• Informsptofphysicalassessmentfindings,notinganyabnormalfindings,potentialdiagnoses,andfollowup.Ifthereareabnormalfindingsduringexam,implementerwillreviewwithprimarycareprovider.

• Patientisinformedoftheimportanceofcontactnotificationintheeventofpositiveresults–implementertoupdatecontactinformationineMRifrequired.

• Implementertofollowupwithlabresultspromptlywhenavailableandreviewthesefindingswiththepatient’sprimarycareproviderinatimelymannersothatappropriatetreatmentorfollowupcareisimplemented.Implementerwillensurethatresultsarecommunicatedwithpatientandthattreatmentand/orfollowuptestingiscompletedasperguidelines.

DocumentationandCommunication: AppendixAttached:XNo___Yes

Title:• Documentationinthepatient’seMRneedstoinclude:nameandnumberofthedirective,name

oftheimplementer(includingcredential),andnameofthephysician/nursepractitionerauthorizerresponsibleforthedirectiveandpatient,usingTCFHTStamp.

• Informationregardingimplementationoftheprocedureandthepatient’sresponseshouldbedocumented,inthepatient’seMR,inaccordancewithstandarddocumentationpractice(CollegeofNursesofOntario,2008).

• Standarddocumentationisrecommendedforprescriptions,requisitions,andrequestsforconsultation.

• ImplementerwillsendamessageinPracticeSolutionstopatient’sprimarycareprovider,notifyinghim/herthatpatientwasseen,andtoreviewnoteineMRfordetails.

ReviewandQualityMonitoringGuidelines: AppendixAttached:XNoYes

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Title:• Routinereviewwilloccurannuallyontheanniversaryoftheactivationdate.Reviewwillinvolve

acollaborationbetweentheauthorizingprimarycareprovidersandtheauthorizedimplementers.

• Ifnewinformationbecomesavailablebetweenroutinereviews,suchasthepublishingofnewclinicalpracticeguidelines,andparticularilyifthisnewinformationhasimplicationsforunexpectedoutcomes,thedirectivewillbereviewedbytheauthorizingphysician/nursepracititionerandamimimumofoneimplementer.Atanysuchtimethatissuesrelatedtotheuseofthisdirectiveareidentified,TCFHTmustactupontheconcernsandimmediatelyundertakeareviewofthedirectivebytheauthorizingprimarycareprovidersandtheauthorizedimplementers.

• Thismedicaldirectivecanbeplacedonholdifroutinereviewprocessesarenotcompleted,orifindicatedforanadhocreview.Duringthehold,implementerscannotperformtheproceduresunderauthorityofthedirectiveandmustobtaindirect,patient-specificordersfortheprocedureuntilitisrenewed.

References:CancerCareOntario.(2012).OntarioCervicalScreeningCytologyGuidelinesSummary.Retrievedfromhttps://www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=13104Carusi,D.A.,&Goldstein,D.P.(2013).Thegynecologichistoryandpelvicexamination.Retrievedfromhttp://www.uptodate.com/contents/the-gynecologic-history-and-pelvic-examination?source=search_result&search=bimanual+exam&selectedTitle=1%7E150CollegeofNursesofOntario.(2008).PracticeStandard:Documentation.Retrievedfromhttp://www.cno.org/Global/docs/prac/41001_documentation.pdfGamma-Dynacare.(2014).Testinformation.Retrievedfromhttp://www.gamma-dynacare.com/Content/HealthcareProviders/TestInformation.aspx?expandable=1Jarvis,C.,Browne,A.,MacDonald-Jenkins,J.,&Luctkar-Flude,M.(2014).PhysicalExaminationandHealthAssessment:SecondCanadianEdition.Joyce,C.&Piterman,L.(2011).TheworkofnursesinAustraliangeneralpractice:Anationalsurvey.InternationalJournalofNursingStudies,48,70-70.Mills,J.&Fitzgerald,M.(2008).Renegotiatingrolesaspartofdevelopingcollaborativepractice:Australiannursesingeneralpracticeandcervicalscreening.JournalofMultidisciplinaryHealthcare,1,35-43.PublicHealthAgencyofCanada.(2013).CanadianGuidelinesonSexuallyTransmittedInfections.Retrievedfromhttp://www.phac-aspc.gc.ca/std-mts/sti-its/index-eng.phpPublicHealthOntario.(2014).Herpessimplex–Skinandgenital.Retrievedfrom

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http://www.publichealthontario.ca/en/ServicesAndTools/LaboratoryServices/Pages/Herpes_simplex_Skin_genital.aspx-.U0WNNlwihg0PublicHealthOntario.(2014).VirusCultureKitsN-0081.Retrievedfromhttp://www.publichealthontario.ca/en/ServicesAndTools/LaboratoryServices/Pages/KitInstructionSheets/Virus-Culture.aspx-.U0WNm1wihg0Stewart,R.,Thistlethwaite,J.,&Buchanan,J.(2009).Canruralpracticenurses,physicianassistantsandnursepractitionersfulfillpatientexpectationsregarding“WellWomanChecks”?10thNationalRuralHealthConference.Retrievedfromhttp://eprints.jcu.edu.au/5328/Thistlethwaithe,J.(2010).Paptests:Whatdowomenexpect?AustralianFamilyPhysician,39(10),775-778.WhiteHilton,L.,Jennings-Dozier,K.,Bradley,P.,Lockwood-Rayermann,S.,DeJesus,Y.,Stephens,D.etal.(2003).TheRoleofNursinginCervicalCancerPreventionandTreatment.Cancer,98(S9),2070-2074.NOTE:ThismedicaldirectiveisbasedonTCFHT’spreviousmedicaldirectiveRN-2PELVICentitled,“PelvicExamination,”whichrequiredrevisioninformattingtoreflectthegrowthoftheTCFHTorganization.ThemajorityofthecontentofRN-2PELVIChasremainedthesamefortherevisedTCFHT-MD06version.Therefore,allapprovedImplementersandAuthorizersformedicaldirectiveRN-2PELVIC“PelvicExamination,”havegrandfatheredapprovalforTCFHT-MD06“PelvicExamination.”

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AppendixA:

AuthorizerApprovalForm

NameSignatureDate

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

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AppendixB:

ImplementerApprovalForm

Tobesignedwhentheimplementerhascompletedtherequiredpreparation,andfeeltheyhavethe

knowledge,skill,andjudgementtocompetentlycarryouttheactionsoutlinedinthisdirective.

NameSignatureDate

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

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AppendixC

SampleLabRequisition

Specimen Collection

x Biochemistry x Hematology x Viral Hepatitis (check one only)Glucose Random Fasting CBC Acute Hepatitis

HbA1C Prothrombin Time (INR) Chronic Hepatitis

Creatinine (eGFR) Immunology Immune Status / Previous ExposureSpecify: Hepatitis A Hepatitis B Hepatitis Cor order individual hepatitis tests in the“Other Tests” section below

Uric Acid Pregnancy Test (Urine)

Sodium Mononucleosis Screen

Potassium Rubella

Chloride Prenatal: ABO, RhD, Antibody Screen(titre and ident. if positive)CK Prostate Specifi c Antigen (PSA)

ALT Repeat Prenatal Antibodies Total PSA Free PSA

Insured – Meets OHIP eligibility criteriaUninsured – Screening: Patient responsible for payment

Alk. Phosphatase Microbiology ID & Sensitivities(if warranted)Bilirubin

Albumin CervicalLipid Assessment (includes Cholesterol, HDL-C, Triglycerides, calculated LDL-C & Chol/HDL-C ratio; individual lipid tests may be ordered in the “Other Tests” section of this form)

Vaginal Vitamin D (25-Hydroxy)Vaginal / Rectal – Group B Strep Insured - Meets OHIP eligibility criteria:

osteopenia; osteoporosis; rickets;renal disease; malabsorption syndromes;medications affecting vitamin D metabolism

Uninsured - Patient responsible for payment

Albumin / Creatinine Ratio, Urine Chlamydia (specify source):

Urinalysis (Chemical) GC (specify source):

Neonatal Bilirubin: Sputum

Child’s Age: days hours Throat Other Tests - one test per lineClinician/Practitioner’s tel. no. ( ) Wound (specify source):

Patient’s 24 hr telephone no. ( ) Urine

Therapeutic Drug Monitoring: Stool Culture

Name of Drug #1 Stool Ova & Parasites

Name of Drug #2 Other Swabs / Pus (specify source):

Time Collected #1 hr. #2 hr.

Time of Last Dose #1 hr. #2 hr.

Time of Next Dose #1 hr. #2 hr.

Fecal Occult Blood Test (FOBT) (check one) FOBT (non CCC) ColonCancerCheck FOBT (CCC) no other test can be ordered on this form

Laboratory Use Only

Time Date

Ministry of Healthand Long-Term CareLaboratory RequisitionRequisitioning Clinician / Practitioner

Laboratory Use Only

Name

Address

Clinician/Practitioner Number

Additional Clinical Information (e.g. diagnosis)

Note: Separate requisitions are required for cytology, histology / pathology and tests performed by Public Health Laboratory

Patient’s Last Name (as per OHIP Card)

Patient’s First & Middle Names (as per OHIP Card)

Patient’s Address (including Postal Code)Copy to: Clinician/PractitionerLast Name

I hereby certify the tests ordered are not for registered in or out patients of a hospital.

XClinician/Practitioner Signature

4422-84 (2012/11) © Queen’s Printer for Ontario, 2012 7530-4581

Date

Address

First Name

24 hour clock yyyy/mm/dd

OHIP/Insured Third Party / Uninsured WSIB

M F

Check (�) one: Province Other Provincial Registration Number Patient’s Telephone Contact Number

CPSO / Registration No. Health Number Version Date of Birth

Service Dateyyyy

yyyy

mm

mm

dd

ddSex

Clinician/Practitioner’s Contact Number for Urgent Results

( )

( )

Specify one below:

Rebekah Barrett, RN Medical Directive TCFHT-MD06

TCFHT-MD06_PelvicExamination

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AppendixD

SampleCytologyRequisition

1964/03/27

ON

Millhouse

Michael

2:52PM 416 417-28092014/04/09

09-04-2014

...

09/04/2014

123 Bay StreetToronto ON

M1F 3G5

Rebekah Barrett, RN Medical Directive TCFHT-MD06