Well Woman Healthcheck Program - Breastand Cervical Cancer Screening Form

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Chart #
Well Woman HealthCheck Program – Breast and Cervical Cancer Screening Form
Contractor/Location:
Provider:
Last Name:
First Name:
DOB:
/
/
BREAST SCREENING
CERVICAL SCREENING
Has the patient presented with breast symptoms?
Has the patient had a hysterectomy?
☐ YES ☐ NO
YES
If yes, is the cervix present?
☐ YES
☐ NO
NO
Was the hysterectomy performed due to CIN or
☐ YES
☐ NO
UNKNOWN
invasive cervical cancer?
Clinical Breast Exam
Date:
/
/
Previous pap test?
1 Normal exam
☐ YES
Date:
/
/
2 Benign finding
☐ NO
3 Bloody or serous nipple discharge*
☐ UNKNOWN
4 Discrete palpable mass (suspicious for cancer)*
Pelvic Exam
Date:
/
/
5 Discrete palpable mass (previously diagnosed as benign)
☐ 1 Normal
6 Nipple or areolar scaliness *
☐ 2 Abnormal – not suspicious for cancer
7 Not done – normal CBE in past 12 months
☐ 3 Abnormal – suspicious for cancer
8 Not done – other or unknown reason
☐ 4 Not done – normal pelvic exam in past 12 months
9 Refused
☐ 5 Not done – other or unknown reason
☐ 10 Skin dimpling or retraction *
☐ 6 Not indicated or not needed
☐ 11 Not done – normal CBE in last 12 months
☐ 7 Refused
Previous mammogram?
Pap Test
Date:
/
/
Indication for Pap Test:
YES
Date:
/
/
☐ 1 Routine Pap test
NO
☐ 2 Breast record only, cervical services not done
UNKNOWN
☐ 3 DX referral
Mammography
/
/
Date:
☐ 4 Pap test not done, proceeded directly to diagnostic or HPV test
☐ 5 Patient under surveillance for a previous abnormal test
Indication for mammogram:
☐ 6 Unknown
1 Routine screening mammogram
2 Cervical record only, breast services not done
Specimen Type
Pap Test Adequacy
3 DX referral
☐ 88142 Liquid
☐ Satisfactory
4 Mammogram not done, CBE only or proceeded directly to DX
☐ 88164 Conventional
☐ Unsatisfactory
5 Symptoms, abnormal CBE or previous abnormal mammogram
☐ 88175 Liquid and manual rescreening
Pap Test Findings:
Mammography Type
☐ 1 Negative for intraepithelial lesion or malignancy
77055 Diagnostic Mammogram Unilateral – Conventional
☐ 2 Adenocarcinoma *
77056 Diagnostic Mammogram Bilateral – Conventional
☐ 3 AGC (Atypical Glandular Cells) *
77057 Screening Mammogram Bilateral – Conventional
☐ 4 AIS (Adenocarcinoma in situ) *
G0202 Screening Mammogram Bilateral – Digital
☐ 5 ASC-H (Atypical squamous cells cannot exclude HSIL) *
G0204 Diagnostic Mammogram Bilateral – Digital
☐ 6 ASC-US (Atypical squamous cells of undetermined significance)
G0206 Diagnostic Mammogram Unilateral – Digital
☐ 7 High grade SIL *
☐ 8 Low grade SIL / HPV *
Mammography Results
☐ 9 Result unknown, presumed abnormal, non-program funded
1 Negative (BI-RADS 1)
☐ 10 Result pending
2 Assessment is incomplete, need additional imaging (BI-RADS 0) *
☐ 11 Squamous cell carcinoma *
3 Benign finding (BI-RADS 2)
HPV Test
☐ CPT Code - 87624
Date:
/
/
4 Film comparison required (BI-RADS 0)
☐ Positive
☐ Negative
☐ Test not done
5 Highly suggestive of malignancy (BI-RADS 5) *
6 Result unknown, presumed abnormal, non-program funded
* Diagnostic Work-up
7 Probably benign (BI-RADS 3)
☐ 1 Planned
8 Result Pending
☐ Colposcopy with biopsy and/or ECC
9 Suspicious abnormality – consider biopsy (BI-RADS 4) *
☐ Gynecological consult
☐ 10 Unsatisfactory
☐ Diagnostic LEEP (needs prior authorization)
* Work-up
☐ Endometrial biopsy
☐ 1 Needed or planned
☐ 2 NOT planned
☐ Additional mammographic views (diagnostic)
Pap ☐ 1 yr ☐ 2 yr
☐ 3 yr
☐ 5 yr
☐ Short term
Months
☐ Surgical consult
☐ 3 Not yet determined
☐ Ultrasound
☐ 2 NOT needed/planned, follow/return to routine screening
Clinician’s Signature
☐ Annual
☐ Short term
Months
☐ 3 Not yet determined
Date
OFFICE VISIT
☐ 99201 – New Patient 10 min
☐ 99202 – New Patient 20 min
☐ 99203 – New Patient 30 min
☐ 99211 – Established Patient 5 min
☐ 99212 – Established Patient 10 min
☐ 99213 – Established Patient 15 min
☐ 99214 – Established Patient 25 min
Rev. 01/15 6-WWH-012
White – Chart
Yellow – ADHS
Pink - Contractor

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