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