Pap/HPV Results Follow-Up Note

Date of Contact: [date and time]

Contact Method: [phone / portal message / letter / in-person]

Patient Reached: [Yes / No]

Results Reviewed

Collection date: [date]

Cytology (Bethesda): [NILM / ASC-US / LSIL / HSIL / ASC-H / AGC / other]

hrHPV result: [Positive / Negative / Not performed]

HPV genotype: [16 / 18 / Other high-risk / Not performed]

Additional findings: [reflex testing performed, amended report, discordant results, or specimen adequacy issues if clinically relevant] (Omit if none.)

Assessment

Guideline framework: [ASCCP 2019 risk-based management / other] (Decision support: [ASCCP app / EHR CDS / none])

Key inputs: [current results, relevant prior screening history, prior treatment, age, special population considerations if any]

Management recommendation: [routine screening in X years / repeat HPV-based testing in 1 year / repeat HPV-based testing in 3 years / colposcopy / expedited treatment preferred / expedited treatment acceptable / specialty referral]

Rationale: [1–2 sentences linking result pattern and history to chosen action; if two acceptable pathways exist, note reason for choice; if prior history unknown, state how management was determined]

Expedited treatment: [eligibility criteria met; shared decision-making occurred] (Include only if expedited treatment discussed.)

Communication

If patient reached:

Result explanation: [plain-language description of what result means, clarification that abnormal screening does not equal cancer when accurate, why follow-up matters]

Next step discussed: [repeat testing vs. colposcopy, expected timeframe, when to seek care sooner]

Patient understanding: [summary of teach-back response]

Patient decision: [accepts recommended follow-up / declines] (If declines: [reason, counseling provided, safety-net plan])

If patient not reached:

Contact attempts: [chronological list: date/time, method, outcome for each attempt; note confidentiality constraints if applicable]

Next steps: [next planned attempt date/method and escalation approach]

Plan

Orders placed: [colposcopy referral with priority / repeat HPV-based testing order with interval / other orders as indicated]

Scheduling status: [scheduled with date / referral sent awaiting scheduling / pending patient action / deferred with reason]

Tracking: [target completion date; responsible party; tracking location (EHR recall, registry, workqueue); escalation steps if incomplete]

Closure criteria: [colposcopy completed with results reviewed / repeat testing completed / patient declined after counseling / care transferred with receiving provider documented]

Patient education provided: [topics and delivery method] (Omit if none.)

Information gaps: [missing items and interim plan to obtain] (Include only if gaps prevent guideline-based recommendation.)