COLPOSCOPY EVALUATION

Please complete the evaluation of the procedure based on your direct observation of the resident.

Write comments in the box at the bottom of the form and complete the competency rating.

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Risk Factors:

1.  Known to physician Yes No

2.   Risk factors assessed Yes No

Professionalism

1. Procedure explained to reduce anxiety Yes No

2. Appropriate demeanor during procedure Yes No

3. Obtain feedback during procedure Yes No

Colposcopy

1. External genitalia examined Yes No

2. Adequate cervical exposure Yes No

3. Transition zone visualized Yes No

4. Pap performed properly Yes No

5. Acetic acid wash done Yes No

6. Exam of endocervix Yes No

7. Recognition of normal anatomy Yes No

8. Accurate description of abnormal areas Yes No

9. Endocervical curettage done (if indicated) Not indicated Yes No

10. Lugol's Stain (if indicated) Not indicated Yes No

11. Proper selection of biopsy areas Yes No

12. Accurate colposcopic grading of lesions Yes No

Comments:

Post Procedure Activities

1. Proper documentation of the procedure Yes No

2. Maintained proper universal precautions Yes No

3. Appropriate follow-up studies recommended. Yes No

4.  Explanation of findings to the patient. Yes No

Overall Comments:

Competency Rating:
1 = Required full supervision
2 = Technical assistant required
3 = Minimal assistance required
4 = Fully competent to perform independently

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