| | Comprehensive colposcopy practice | Minimum colposcopy practice |
| Precolposcopy evaluation | Evaluate and document at least the following: - Indications for colposcopy
- History of cervical cytology, colposcopy, treatment
- Parity
- Contraception
- Pregnancy status
- Menopausal status
- Hysterectomy status
- Smoking history
- HIV status
- HPV vaccination status
| Evaluate and document at least the following: - Indications for colposcopy
- Pregnancy status
- Menopausal status
- Hysterectomy status
|
| Obtain informed consent. | Obtain informed consent. |
| Examination | Examine vulva and vagina grossly. | Examine vulva and vagina grossly. |
| Examine the cervix with multiple magnifications after application of 3 to 5% acetic acid. | Examine the cervix with magnification after application of 3 to 5% acetic acid. |
| Examine cervix with both white light and a red-free (blue or green) filter. | |
| Examine upper vagina with magnification. | |
| Documentation | Document findings using a diagram or photograph, annotated if possible. Findings should be imported into electronic medical record. | Document findings at least in text format. |
| Document cervix visibility (fully/not fully visualized). | |
| Document SCJ visibility (fully/not fully visualized) and whether cervical manipulation is needed to completely visualize the SCJ (eg, using an applicator stick or endocervical speculum). | Document SCJ visibility (fully/not fully visualized). |
Document colposcopic findings: - Acetowhitening present (yes/no)
- Lesion(s) present (yes/no)
- If lesion(s) present, document extent of lesion(s) visualized (fully/not fully), lesion size and location, description (color, contour, border, vascular changes)
| Document colposcopic findings: - Acetowhitening present (yes/no)
- Lesion(s) present (yes/no)
|
| Document a colposcopic impression (benign-normal/low-grade/high-grade/cancer). | Document a colposcopic impression (benign-normal/low-grade/high-grade/cancer). |
| Biopsy | If biopsies are indicated, take biopsies at the SCJ and document their location. | If biopsies are indicated, take biopsies at the SCJ. |
| Document whether endocervical sampling performed and method: curette versus brush or both. | Document whether endocervical sampling performed. |
| Postprocedure | Document how patient will be notified of results and management plan. | Make arrangements to notify patient of results. |
