PAP smear (GP)
Created by
Grace Wong
Specialty
General Practitioner
Last edited
10/20/2026
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0 times
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About this template
This template supports general practitioners in documenting cervical screening, including patient and clinical information, procedure details, results, and follow-up. It is intended to promote complete records, continuity of care, and patient education for routine PAP smears.
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PAP Smear
Patient Information
- Name: Sarah Jenkins
- DOB: 14/08/1989
- MRN / PHN: 9847 362 109
Clinical Information
- Date of PAP smear: 24/10/2023 at 10:15
- Reason for PAP smear: Routine cervical screening (last screening 10/2020, NILM). Asymptomatic; no PCB, IMB, or abnormal vaginal discharge.
- Relevant medical history: G2P2 (2x SVD). LMP 10/10/2023, regular 28-day cycles. Up to date on HPV vaccination (Gardasil 9 completed). Non-smoker.
- Current medications: levonorgestrel (Mirena®) 52 mg IUD in situ (inserted 2021); escitalopram (Cipralex®) 10 mg PO daily.
- Allergies: NKDA.
Procedure Details
- Description of the procedure: Informed consent obtained. Chaperone declined. Patient positioned in dorsal lithotomy. Warmed, water-lubricated medium graves speculum inserted easily. Cervix visualised. Ectocervical and endocervical cells sampled using cervical broom and placed directly into ThinPrep liquid-based cytology vial. Endocervical swab obtained for STI screening. Speculum removed.
- Findings during the procedure: Normal external genitalia. Vaginal mucosa pink, moist, no lesions or abnormal discharge. Cervix parous, pink, smooth, no ectropion, polyps, or friability. IUD strings visualised at external os, normal length.
- Any complications or issues encountered: Procedure tolerated well. Mild spotting post-sampling, resolved spontaneously.
Results
- Cytology results: Pending (routine lab turnaround 2–3 weeks).
- HPV test results: Reflex HPV testing ordered if ASC-US; primary result pending.
- Other relevant test results: Endocervical NAAT for Chlamydia trachomatis and Neisseria gonorrhoeae pending. Urine hCG negative.
Follow-Up
- Recommended follow-up actions: Routine screening in 3 years if NILM. Clinic to notify patient only if results are abnormal, or patient can view results via provincial health portal.
- Next appointment date: 24/10/2026 (or PRN if abnormal results).
- Patient education and counselling provided: Advised on expected mild spotting/cramping for 24 hours. Instructed to return if experiencing heavy vaginal bleeding, foul-smelling discharge, fever, or pelvic pain. Discussed routine screening intervals per BC Cancer guidelines.
How to use this template
This template can be used to assist with various tasks in the medical field. You can use it to generate notes, manage patient information, or assist with diagnosis and the Assessment and Plan. To use this template, simply click the “Use Template” button above. If you have any questions or need assistance, feel free to reach out to the support team or refer to the description and example output provided above.