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Montana Title X Family Planning

Clinical Protocol Manual

Table of Contents

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Clinical Protocol Manual Cover Page
State Seal Page
Revision Page
Table of Contents
Guide to Use of Manual
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 11/19
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 11/19

3 - Combined Contraceptives

Revision Date
3-0 Combined Hormonal Contraceptives 1/19
3-1 Extended Combined Hormonal Contraceptives 11/19
3-2 Headache Evaluation 1/19
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 1/19

4 - Progestin Only Contraceptives

Revision Date
4-1 Depo Provera (DMPA) 11/19
4-2 Progestin Only Mini Pill POP 1/19
4-3 Emergency Contraceptive Pills 1/19
4-4 Subdermal Implant 10/17

5 - Intrauterine Contraceptive (IUC)

Revision Date
5-1 IUC Candidate/Insertion/Removal of Device 11/19
5-2 IUC Complication- Excessive or Unscheduled Bleeding Pattern Variations 10/17
5-3 IUC Complication- Expulsion 10/17
5-4 IUC Complication- Infection 10/17
5-5 IUC Complication- Missing String(s) 10/17
5-6 IUC Complication- Perforation 10/17
5-7 IUC Complication- Pregnancy 10/17

6 - Other Methods

Revision Date
6-1 Abstinence 1/19
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 1/19
10-6 Gonococcal Infection 11/19
10-7 Hepatitis B 1/19
10-8 Hepatitis C 1/19
10-9 HIV Testing 11/19
10-10 Syphilis 11/19
10-11 Trichomoniasis 1/19
10-12 Vaginitis-Atrophic 10/17
10-13 Molluscum Contagiosum 10/17
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 10/17
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 10/17
12-3 Breast Imaging Guidelines 11/19
12-4 Cervical Cytology Management 10/17
12-5 Dysmenorrhea 10/17
12-6 Lactating Mastitis, Breast Engorgement or Breast Abscess 10/17
12-7 Pelvic Inflammatory Disease 10/17
12-8 Premenstrual Syndrome 10/17
12-9 Secondary Amenorrhea 10/17
12-10 Toxic Shock Risks 10/17
12-11 Urinary Tract Infection 10/17
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