7.2 Procedural Outline

Part II: Guidelines for Client Services and Clinic Management


  1. Initial Visit:
  2. Return Visits:

Services provided to a client at a family planning visit, and the sequence in which they are provided, will depend on the type of visit and the services requested/needed by the client. According to the Title X guidelines and Illinois mandates, there are certain services that must be offered and provided to family planning clients. The required services are listed below, grouped by visit types. The delegate agency must make every effort to promote client acceptance of services required with the provision of a prescription contraceptive method. However, the client has the right to refuse any service. Refusal and the reason for refusal must be carefully documented.

Initial Visit:

The following services must be provided and documented for all clients at the initial visit:

Education:

Present individualized relevant information and educational materials based on the client needs and knowledge. Education materials may be used in addition to support verbal discussion and may include pamphlets and brochures and audio-visual materials. (Refer to Section 8.1 for the content requirements of Client Education).

Counseling:

Conduct an interactive process in which the client is assisted in making an informed choice. Refer to Section 8.2 for the content requirements of Counseling.

Informed Consent:

Explain all procedures and obtain general consent covering examination and treatment and, where applicable, a method specific consent. Refer to Section 8.1 for requirements related to obtaining Informed Consent.

History:

Obtain a comprehensive personal and family medical and social history. Refer to Section 8.3 for the requirements of a complete History.

Laboratory Testing:

Perform routine testing and other lab tests as indicated. Refer to Section 8.3 for the requirements for Laboratory Testing.

Examination:

Perform a complete physical assessment and any necessary clinical procedures as indicated. New clients may elect to defer the initial exam under certain program guidelines. Refer to Section 8.3 for the requirements of a complete Physical Assessment and Examination Deferrals.

Follow-up and/or Referrals:

Plan for a mechanism for client follow-up (e.g., how a client will be notified of abnormal test results, how a client will be contacted if she/he misses a follow-up/referral appointment, etc.); performance of any other clinical procedures; provision of medications and/or supplies as needed; and provision of referrals as needed. For clients who request "No Contact" status, an alternative mechanism for emergency contact must be established. Refer to Section 7.4 for the requirements for Referrals and Follow-Up.

Return Visits:

Return visits (annual, problem, and routine) should include an assessment of the client's status, current complaints, and evaluation of the birth control method, as well as an opportunity to change methods. The exception is routine supply visits. The following components must be offered and documented for all clients at the return visit:

Counseling:

Determine the nature of the follow-up visit. Discuss the client's use of and proficiency with the contraceptive method, any side effects, satisfaction with the method, and change of method, if necessary. Counseling at annual visits is not billable except in documented non-routine situations (e.g., method change or problem).

History:

Update the personal and family medical and social history.

Examination:

Perform either a complete physical assessment or a focused exam based on the reason for the visit, plus any necessary clinical procedures, if indicated.

Laboratory Testing:

Perform routine and other indicated lab tests.

Follow-up and/or Referrals:

Review the mechanism for client follow-up; discuss additional laboratory test(s) and/or referral(s) to appropriate outside medical resources as necessary; provide medications and/or supplies as needed; inform client of the follow-up return visit schedule and offer any additional counseling based on the client needs.

Regardless of the purpose of the visit, service delivery to all clients must include:

  • Courteous service and treatment that is provided with dignity and respect;
  • The opportunity for clients to participate in the planning of their medical treatment;
  • Encouragement for clients to voice any questions or concerns;
  • Materials and/or interpreters available for those with limited ability to read or understand English and for those who may be blind or hearing impaired.

A summary of the required IDHS Minimum Requirements for Routine Health Care is presented in the Table 1 below:

Reproductive Health Care Initial Visit
Female ClientsY*
Annual / Revisits
Female ClientsX*
History - Section 8.3
Complete Medical History: Y Update
Personal, Family, Social and Partner Y Update
Reproductive Function Y Update
Colo-rectal Cancer Risk Assessment >40 Y Y
Written Informed Consent-Section 8.1
Consent for Services Y Update if changes
Method Specific Consent Y Update if changes
Physical Assessment - Section 8.3
General including: Thyroid/Heart/Lungs/ Extremities/Abdomen Y1,2 Y2
Ht, Wt, Blood Pressure Y2 Y2
External Genitals Y1,2 Y2
Pelvic exam (includes bi-manual) Y1,2 Y2- Y within 3/mo - IUD
Breast exam Y1,2 Y2
Laboratory Tests - Section 8.3
Specific tests if required in the provision of a contraceptive method.
Pap test Y1,2, per protocol (Y-per protocol)2
HGB &/or HCT Y2 Y2
Chlamydia test (Y)2 (Y)2
Gonorrhea test (Y)2 (Y)2
Vaginal wet mount (Y)2 (Y)2
Diabetes testing (fasting glucose) (Y)2 (Y)2
Total cholesterol and lipids (Y)2 (Y)2
Syphilis test (Y)2 (Y)2
Urinalysis Y2 (X)2
Fecal occult blood >50 Y2 Y2
Counseling & Education - Section 8.2
Contraceptives, STD, HIV Y Y (Update)
Breast self exam Y Y
Preconception (Routine Required) Y Y
Minors - abstinence, family involvement, relationship safety Y Y
Health Promotion - smoking cessation, nutrition, exercise, substance abuse, etc. (X) (X)
Follow-up and Referrals - Section 7.4 Y Y

1 = may be deferred 3 mos., maximum 6 mos., unless compelling reason

2 = on-site or by referral

X*: X= recommended ("SHOULD" per guideline) (X) = recommended as indicated

Y*: Y= required ("MUST" per guideline) (Y)= required as indicated


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