8.3 History, Physical Assessment and Laboratory Testing

Part II: Guidelines for Client Services and Clinic Management

  1. History:
  2. Physical Assessment:
  3. Laboratory Testing:


At the initial comprehensive clinical visit, a complete medical history must be obtained on all female clients. Pertinent changes in the client's health history must be updated at subsequent clinical visits. The history must be taken in a language understood by the client, whether directly or through an interpreter.

The history must include:

  • Significant illnesses, e.g., cardiac disease, embolic disease, cancer, pelvic infection, hospitalizations, surgeries, blood transfusions or exposure to blood products, and chronic or acute medical conditions;
  • Allergies/drug reactions;
  • Current use of prescription and over-the-counter medications;
  • Extent of use of tobacco, alcohol and other drugs;
  • Immunizations, including rubella, tetanus and hepatitis status;
  • Review of systems;
  • Pertinent history of immediate family members;
  • For women 40 years or above, screening history for colorectal cancer risk
  • Depression or other mental health problems;
  • Family or intimate partner violence;
  • Coercion of minors to engage in sexual activity; and
  • Partner history, including injection drug use, multiple sexual partners, risk history for STDs and HIV, and bisexuality.

Histories of reproductive function in female clients must include at least the following:

  • Menstrual history;
  • Sexual history;
  • Obstetrical history;
  • Gynecological conditions;
  • Sexually Transmitted Diseases;
  • HIV;
  • Pap test history (date of last pap, any abnormal pap and treatment);
  • History of blood transfusion prior to 1984;
  • In utero exposure to diethylstilbestrol (DES), if born between 1940 and 1970. (Clients with prenatal exposure to exogenous estrogens should receive information/education and special screening either on site or by referral);
  • Past and current contraceptive use, including adverse effects and reason for discontinuation, as well as the method desired; and
  • Assessment of contraindications for use of contraceptive methods.

The health history may be a self-administered form that must be completed by all new clients prior to the physical examination. The client should be instructed on how to fill out the form and staff should answer any questions the client may have. Clients should sign and date the form in the appropriate spaces. After reviewing the form, questioning the client appropriately, and charting any additional information, the clinician must sign and date the form in the appropriate spaces.

A medical history update must include the following:

  • Recent illness, medical problems or surgery;
  • Pregnancy;
  • Contraceptive method problems;
  • Changes in smoking or drug use behaviors;
  • Changes in medications used;
  • Changes in sex partner risk history; and
  • Pertinent changes in health of first order relatives

Physical Assessment:

For many clients, family planning programs are their only source of continuing health information and clinical care. Therefore, all female clients should have a complete physical assessment at the initial and annual return visits.

For all clients the complete physical examination includes:

  • Height and weight;
  • Blood pressure evaluation;
  • Thyroid palpation;
  • Auscultation of the heart and lungs;
  • Examination of extremities;
  • Clinical breast examination and instruction for the client in breast self examination;
  • Abdominal palpation;
  • Pelvic examination that includes visualization of the genital area, vagina and cervix and bimanual examination;
  • Laboratory specimen collection for pap tests and STD screening, as indicated. (Refer to Laboratory Testing below for additional information); and
  • Rectal examination and fecal occult blood test for individuals over 50. (Women 40 years or older must be assessed for colorectal cancer risk. If at risk, the fecal occult blood test must be offered annually.)

All physical examination and laboratory test requirements stipulated in the prescribing information for specific methods of contraception must be followed.

Following counseling about the importance of prevention services, if a client chooses to decline or defer a service, this must be documented in their medical record. Counseling must include information about the possible health risks associated with declining or delaying preventative screening tests or procedures.

Physical examination and related prevention services should not be deferred beyond 3-6 months after the initial visit, and in no case may be deferred beyond 6 months, unless in the clinician's judgment, there is a compelling reason for extending the deferral. All deferrals, including the reason(s) for deferral, must be documented in the client medical record. No deferral may extend beyond 12 months. All exams deferred beyond six months must be documented in a log for the IDHS annual clinical review.

IDHS has developed detailed guidance for protocol development, sample fact sheets and an assessment form for the provision of hormonal contraception without a pelvic exam for delegate agency use. These documents are included in Appendix I of this manual.

Laboratory Testing:

Laboratory tests can be important indicators of client health status and useful for diagnostic purposes. Certain laboratory tests are required for the provision of specific methods of contraception. Counseling should inform clients about the recommended tests as well as the limitations of specific tests (for example, false negatives or positives). The following lab procedures must be made available to clients on site or by formal referral, provided to clients if required in the provision of a contraceptive method, and may be provided for the maintenance of health status and/or diagnostic purposes:

  1. Chlamydia Test
  2. Gonorrhea Test
  3. Fasting Glucose Test
  4. Fecal Occult Blood test
  5. Hemoglobin or Hematocrit
  6. Herpes Test
  7. HPV/DNA Test
  8. Pap Test
  9. Pregnancy Test
  10. Sickle Cell Test
  11. Syphilis Test
  12. Total Cholesterol
  13. Urinalysis, as indicated (for initial visit clients)
  14. Vaginal Microscopy

Pregnancy Testing:

The pregnancy test is a standard service for family planning clients and must be provided on site. Clients should be encouraged to have the results confirmed by a pelvic examination scheduled within two weeks. Appropriate pregnancy test counseling must be provided. Clients who are pregnant must be offered options counseling and provided with information on prenatal care, adoption and pregnancy termination, as requested. (Refer to section 8.6 "Pregnancy Diagnosis and Counseling" in this manual for detailed information). Those clients who are not pregnant should be provided with contraceptive counseling.

STD Testing and Treatment:

At the initial and annual visits, clients must have a thorough health history and physical assessment that includes screening for risk of STD infection and sexually active women less than 25 years of age will be tested for Chlamydia and Gonorrhea. Risk assessment may indicate the need for more frequent screening than yearly. Clients may also be screened for Chlamydia and Gonorrhea according to the one or more of the following criteria:

  • The client has signs or symptoms of infection, such as vaginal discharge, mucopurulent cervicitis, pelvic inflammatory disease;
  • The client's sex partner was diagnosed with Chlamydia or Gonorrhea;
  • In the past three months, the client has had a new sex partner, more than one sex partner, and/or sex partner with another partner; or
  • The client has a history of an STD in previous three years.

In addition, clients who receive IUD/IUS must be screened for Chlamydia and Gonorrhea per protocol.

Clients who are symptomatic of other STDs should be screened and treated in accordance with the most current Centers for Disease Control and Prevention Sexually Transmitted Diseases Treatment Guidelines.

Refusal of Laboratory Services:

The client has the right to refuse any laboratory test/procedure. If the test is a prerequisite for a procedure or prescription, the client shall be informed that unless the test is done, the procedure cannot be performed or the prescription cannot be given. The client's refusal should be documented in the medical record.

Laboratory Testing Protocol and Quality Assurance:

The IDHS has issued written protocol guidance for Cervical Cancer Screening, Colorectal Cancer Screening and Sexually Transmitted Diseases Screening and Treatment. Delegate agencies must have written laboratory protocols and operating procedures in place for all laboratory testing and follow-up procedures for all abnormal test results. The delegate protocol must reflect the IDHS issued protocol (Refer to Appendix I). A system must be in place to track abnormal findings. The best practice approach is to keep an abnormal log to ensure follow up protocol is observed.

Delegate agencies are required to conduct quality control, equipment maintenance and proficiency testing for on-site lab testing. All family planning clinics must also be in compliance with CLIA regulations, effective September 1992, that apply to their CLIA certification type. A current CLIA certificate should be displayed on site.

When contracting and utilizing the services of an off-site lab the delegate must establish systems to assess the credentials of the contracted lab and to assure high quality lab testing. Cytology services must be provided by laboratories that are compliant with CLIA and State licensure regulations.

Notification, Referral and Follow-Up for Abnormal Test Results:

A procedure must be in place that addresses client confidentiality, notification of test results, and adequate follow-up of abnormal laboratory test results. Clinic staff must establish a mechanism for contacting all "no contact " clients in the event of abnormal lab test results and must document this contact in the medical record where applicable.

Referral and follow-up for abnormal tests must include:

  • Documentation of the appropriate management for abnormalities;
  • All follow-up with the client regarding significant lab results;
  • Referrals for additional necessary services, if not provided on site;
  • Documentation of reasonable attempts to contact the client that is consistent with the severity of the abnormality. (For example: documentation of 3 contacts within 6 weeks, 2 of which will be in writing).

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