36C24219R0014-177.pdf

D.38 WOMEN’S HEALTH BREAST AND CERVICAL CANCER SCREENING RESULTS

NOTIFICATION TRACKING – VA WNY PRIMARY CARE SOP

10/9/2018

Women’s Health Breast and Cervical Cancer Screening Results Notification Tracking VA WNY Primary Care SOP

Reference: VHA DIRECTIVE 1330.01, HEALTH CARE SERVICES FOR WOMEN VETERANS, February 15, 2017

Purpose: ensure tracking and timely follow-up of findings from breast and cervical cancer screening and/or HPV testing completed on women Veterans.

Responsibilities:

1. Women Veterans are notified of breast, cervical cancer screening and HPV test results by the Primary Care Provider (or other ordering Provider) or designee.

a. The ordering provider or designee must communicate the results of normal mammograms, cervical pathology and/or HPV tests completed in-house or through contract or non-VA care to the patient within 14-calendar days from the date the results are available to the ordering provider.

b. The ordering provider or designee must communicate results of mammograms, cervical pathology and/or HPV tests completed in-house or through contract or non-VA care that require action to the patient no later than 7-calendar days from the date the results are available to the ordering provider.

c. Notification by letter and/or verbal communication with the patient must be documented in

CPRS.

2. Process:

a. WH PACT team/designees will use the VISN 2 Data Warehouse “UPSTATE NEW YORK

HCS Women's Health Mammogram, PAP Tracking” report to identify patients who had breast and cervical cancer screening and/or HPV testing completed.

1) WH PACT teams will pull the report monthly, of screening tests completed in previous month, and complete the tracking by end of each month.

2) A column for the following 4 information points will be added to the spreadsheet, for use by WH PACT team member/designee to track notification and timely follow-up:

i. Date available in CPRS

ii. Normal/Abnormal

iii. Date patient informed, documented in CPRS

iv. Status - any need for follow-up and actions taken

3) The monthly report will be saved in the following folder, in each division’s sub-folder:

T:\WNY-PACT-Teamlets\A - PC WNY Daily Operations Logs\A - Womens Health WNY-c

b. WH PACT teams/designees will review monthly data on spreadsheet to track notification and follow-up of actionable results.

1) Comments will be added reflecting review of patient notification and follow-up.

2) Patients who require follow-up as documented by ordering Provider in CPRS will be highlighted in the monthly spreadsheet, and those patients will be added to the FY

Follow-Up spreadsheet for each site, for continued tracking until required follow-up completed/addressed as recommended by ordering Provider.

3. Link to report and how to use:

VISN 2 Data Warehouse https://vaww.fre.cdw.va.gov/sites/D01_VISN02/Pages/VISN2DW.aspx

Click on VISN 2 Upstate Reports

Click on Clinical Reports

Click on PACT Reports https://vaww.fre.cdw.va.gov/sites/D01_VISN02/Pages/VISN2DW.aspx

Scroll down and select Pact WH PAP Mammo Results Tracking report

Select parameters for all clinics at your site/division (ex: both Providers at NF or all Providers at Batavia) – and choose all and specify date range – then select Apply

Go to Actions top left corner, and export to CSV file and save as an EXCEL spreadsheet in your T drive folder as noted in SOP Process instructions