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Primary Care Physician
10-15 minutes

Gynecological/Pap Smear Appointment

The Gyne/PAP Visit template is expertly crafted for family medicine practitioners performing routine gynecological examinations. It encompasses sections for menstrual health, contraception, STI evaluations, and hormone therapy, alongside detailed gynecological and bimanual assessments. This template guarantees thorough documentation of PAP tests and follow-up strategies, making it an indispensable resource for healthcare providers. Optimized for integration with s10.ai, the AI medical scribe, it enhances documentation efficiency and elevates patient care. Perfect for capturing all critical details during a gynecological visit, it facilitates effective and comprehensive record-keeping.

2,059 uses
4.3/5.0
D
Dr. Emily Carter
Template Structure

Organized sections for comprehensive clinical documentation

S:
- Menstrual Status: [LNMP/Peri-Menopause/Menopausal]
- Periods: [regular/irregular]
- Cycle length: [Enter number of days]
- Contraception: [none/CHC/IUD]
- STI concerns: [yes/no]
- Hormone Replacement Therapy: [yes/no]
Last PAP: [Enter date]
History of abnormal PAP: [Details of any abnormal PAP results]
Previous treatments for abnormal PAP: [none/colposcopy/laser/LEEP/cryotherapy/excision]
Hysterectomy: [no/total/subtotal]
[Informed consent obtained]
[Chaperone present]
O:
- General appearance: [Brief description of general appearance]
- Gynecological Exam: [small/medium/large] speculum used to visualize cervix
- Vulva: [Objective findings on vulva]
- External genitalia: [Description of external genitalia]
- Vagina: [pink/pale - signs of estrogen depletion, or other relevant findings]
- Cervix: [Objective cervix findings/description, e.g., "normal, no lesions or discharge," "inflamed with visible lesions," etc.]
- Discharge: [no/yes, specify type if present]
PAP Test: [Procedure details, e.g., "PAP test performed without complications"]
GC, Chlamydia, BV/yeast/trichomonas swabs: [done/not done]
Bimanual Exam: [deferred/No cervical motion tenderness, uterus and ovaries within normal size limits. No masses or abnormalities appreciated, or describe any other findings.]
A/P:
- Diagnosis: [Diagnosis and any relevant findings]
- PAP test status: [Pending results/Normal/Abnormal]
- Follow-up plan: [Follow-up plan, e.g., "Schedule follow-up in 6 months for repeat PAP" or "Refer to colposcopy for abnormal findings."]
- Patient notification plan: [Describe how the patient will be informed of results, e.g., "Patient will be notified via phone or portal of test results."]
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state that it has not been mentioned and instead leave the relevant placeholder blank.)
Sample Clinical Note

Example of completed documentation using this template

S:  
- Menstrual Status: Menopausal  
- Periods: regular  
- Cycle length: 28 days  
- Contraception: none  
- STI concerns: no  
- Hormone Replacement Therapy: yes  
Last PAP: 2022-05-15  
History of abnormal PAP: No history of abnormal PAP results  
Previous treatments for abnormal PAP: none  
Hysterectomy: no  
Informed consent obtained  
Chaperone present  
O:  
- General appearance: Well-nourished, alert, and oriented  
- Gynecological Exam: Medium speculum used to visualize cervix  
  - Vulva: Normal appearance  
  - External genitalia: No lesions or abnormalities noted  
  - Vagina: Pink, no signs of estrogen depletion  
  - Cervix: Normal, no lesions or discharge  
  - Discharge: no  
PAP Test: PAP test performed without complications  
GC, Chlamydia, BV/yeast/trichomonas swabs: done  
Bimanual Exam: No cervical motion tenderness, uterus and ovaries within normal size limits. No masses or abnormalities appreciated.  
A/P:  
- Diagnosis: Routine gynecological exam, no abnormalities detected  
- PAP test status: Pending results  
- Follow-up plan: Schedule follow-up in 6 months for repeat PAP  
- Patient notification plan: Patient will be notified via phone or portal of test results.
Clinical Benefits

Key advantages of using this template in clinical practice

  • This comprehensive gynecological evaluation template is designed to streamline clinical documentation for healthcare professionals, ensuring thorough assessment and accurate record-keeping. It covers essential aspects such as menstrual status, contraception use, and STI concerns, while also documenting the patient's last PAP test and any history of abnormal results. The template facilitates detailed gynecological examinations, including speculum and bimanual exams, with placeholders for objective findings on the vulva, external genitalia, vagina, and cervix. It also includes sections for PAP test procedures and swabs for common infections like GC, Chlamydia, BV, yeast, and trichomonas. The assessment and plan section allows for precise diagnosis documentation, PAP test status updates, and follow-up plans, ensuring patients are informed of their results efficiently. By adopting this template, clinicians can enhance their workflow, improve patient care, and maintain high standards of clinical documentation.
Frequently Asked Questions

Common questions about this template and its usage

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Gynecological/Pap Smear Appointment