Montana Title X Family Planning

Clinical Protocol Manual

Table of Contents

Clinical Protocol Manual Cover Page
State Seal Page
Revision Page
Table of Contents
Guide to Use of Manual
Clinical Protocol Manual Updates Summary
Protocol Review & Revisions Sign Off Page
Commonly Used Acronyms

1 - Comprehensive Health History & Periodic Physical Assessment

Revision Date
1-1 Comprehensive Female Health History & Periodic Physical Assessment 2/21
1-2 Comprehensive Male Health History & Periodic Physical Assessment 11/19
1-3 Reproductive Life Plan 1/19
1-4 Sexual Health Assessment 1/19

2 - Barrier Methods

Revision Date
2-1 Cervical Cap 10/17
2-2 Diaphragm Fitting 11/19
2-3 Diaphragm Check 10/17
2-4 Internal Condom 11/19
2-5 External Condom 11/19
2-6 Vaginal Spermicide 2/21

3 - Combined Contraceptives

Revision Date
3-0 Combined Hormonal Contraceptives 1/19
3-1 Extended Combined Hormonal Contraceptives 11/19
3-2 Headache Evaluation 2/21
3-3 Quick Start/Same Day Start Method 1/19
3-4 Amenorrhea Related to CHC Method 1/19
3-5 Manage Breakthrough Bleeding or Unscheduled Bleeding Related to CHC's 2/21

4 - Progestin Only Contraceptives

Revision Date
4-1 Depo Provera (DMPA) 11/19
4-2 Progestin Only Mini Pill POP 2/21
4-3 Emergency Contraceptive Pills 2/21
4-4 Subdermal Implant 2/21

5 - Intrauterine Contraceptive (IUC)

Revision Date
5-1 IUC Candidate/Insertion/Removal of Device 2/21
5-2 IUC Complication- Excessive or Unscheduled Bleeding Pattern Variations 2/21
5-3 IUC Complication- Expulsion 2/21
5-4 IUC Complication- Infection 2/21
5-5 IUC Complication- Missing String(s) 10/17
5-6 IUC Complication- Perforation 2/21
5-7 IUC Complication- Pregnancy 2/21

6 - Other Methods

Revision Date
6-1 Abstinence 2/21
6-2 Fertility Awareness Based, Natural Family Planning and Fertility Awareness Combined Methods 11/19

7 - Pregnancy Test Results and Counseling

Revision Date
7-1 Positive Pregnancy Test Results and Counseling 11/19
7-2 Negative Pregnancy Test Results and Counseling 11/19

8 - Basic Fertility Services

Revision Date
8-0 Basic Fertility Services 1/19

9 - Preconception Health Services

Revision Date
9-0 Preconception Health Services 1/19

10 - Sexually Transmitted & Other Infections

Revision Date
10-1 Anogenital Lesions - HPV 1/19
10-2 Bacterial Vaginosis (BV) 1/19
10-3 Candidiasis 11/19
10-4 Chlamydia 11/19
10-5 Genital Lesions - Herpes Simplex Virus Infection 2/21
10-6 Gonococcal Infection 11/19
10-7 Hepatitis B 1/19
10-8 Hepatitis C 1/19
10-9 HIV Testing 2/21
10-10 Syphilis 11/19
10-11 Trichomoniasis 1/19
10-12 Vaginitis-Atrophic 2/21
10-13 Molluscum Contagiosum 2/21
10-14 Mucopurulent Cervicitis 10/17
10-15 Patient Delivered Partner Therapy (PDPT) 10/17

11 - Related Preventive Services

Revision Date
11-1 Abuse and/or Violence 11/19
11-2 Elevated Blood Pressure- Pre-hypertension Men and Women 2/21
11-3 Substance Use Disorders 11/19
11-4 Health Screenings 10/17

12 - Preventive Health Services for Women

Revision Date
12-1 Body Mass Index Variances 10/17
12-2 Breast Concerns 2/21
12-3 Breast Imaging Guidelines 11/19
12-4 Cervical Cytology Management 2/21
12-5 Dysmenorrhea 2/21
12-6 Lactating Mastitis, Breast Engorgement or Breast Abscess 2/21
12-7 Pelvic Inflammatory Disease 2/21
12-8 Premenstrual Syndrome 10/17
12-9 Secondary Amenorrhea 10/17
12-10 Toxic Shock Risks 10/17
12-11 Urinary Tract Infection 2/21
12-12 UTI Pyelonephritis 10/17
12-13 Interstitial Cystitis/Bladder Pain Syndrome 10/17

13 - Preventive Health Services for Men

Revision Date
13-1 Hydrocele 10/17
13-2 Penile Skin Lesions 11/19
13-3 Tinea Corporis (Ringworm) 11/19
13-4 Tinea Cruris (Jock Itch) 11/19

14 - Laboratory Tests

Revision Date
14-1 Abnormal Hemoglobin - Elevated 11/19
14-2 Abnormal Hemoglobin - Low 11/19
14-3 Hyperglycemia - Prediabetes 11/19
14-4 Glycosuria 11/19

15 - General Clinical Information

Revision Date
15-1 General Clinical Information 1/19
15-2 Purpose and Content of the Medical Record and Record Retention 11/19
15-3 Standardized Forms 1/19
15-4 Record Security and Record Transport 1/19
15-5 Release of Information 1/19
15-6 Achieving Pregnancy 1/19
15-7 Contraceptive Services 11/19
15-8 RN Contraceptive Starts 1/19
15-9 Sexually Transmitted Infection Services 11/19
15-10 Laboratory Services 1/19
15-11 Pharmacy Policies and Procedures 1/19
15-12 Pharmacy Drug Recall 1/19
15-13 Pharmacy Standing Orders 1/19
15-14 Sample Standing Orders 2/19
15-15 Emergency Medical Services 1/19
15-16 Sample Management of Emergency Medical Services 1/19
15-17 Social Service Referral Guidelines 11/19
15-18 Medical Service Referral Guidelines 11/19
15-19 Immunizations 1/19
15-20 Documentation 1/19