Recording a Smear Result
To record a smear result:
- Select the patient required, because you are editing rather than adding, a consultation need not be started.
- Find the original "smear taken" line, either:
- Find the entry on the Journal tab, right click and select Edit;
- From List, select Cytology. From the displayed list, right click and select Edit. The topmost entry is usually the one to be updated. Right mouse click on the entry to update and select Edit.
- Click in the READ Term for result field. Click on the appropriate result from the displayed list. Make sure that your result code is a four-digit code starting with 4K2 for cervical smears and 4KA for vault smears. This will ensure that searches are reliable and accurate. See the section on Cervical Cytology - READ Codes for Smear Results, which explains their best use.
- Click in the Inflammation Category field if an inflammation is reported, and click on the appropriate entry from the displayed list.
- In Date Smear Reported, you can use the abbreviated date format, T for today's date, or –1D for yesterday, -3D three days ago and so on. You will not be able to click in this field or Tab to it until the READ term has been changed from 685A Ca cervix screen-no result yet.
- Note that a due date is not generated automatically. Click on the Recall icon to record a due date. The Recall – Add screen displays.
- Change the Set Up Date to today's date by typing T and pressing the Tab key.
- Enter the date in the Recall Date field either in the abbreviated format, eg 3y (for three years) or 6m (for six months) or as an actual date. Note that if you enter the date in the 3y or 6m format, the actual date will only be displayed when you move to the next field or when you click on the OK button.
In READ Term for Recall Trigger, this will default to whatever the READ term result is on the front Cervical Cytology Add screen.
In READ Term for Recall Reason, this again defaults to the same READ code. You could if you like double click on this window for the READ Dictionary select screen, and change the recall reason.
It should be one of the following READ codes to trigger a recall - note that all their lower level codes will be included as well, eg 4K21, 4K22 etc.
- 4K2.. Cervical smear result
- 4KA.. Vaginal vault smear result
- 685.. Cervical neoplasia screen (or cervical cytology screen)
- 4K4.. Cervical smear - action needed
- 9O8.. (note - this is O not zero) - Cervical smear screen admin
- K55.. Noninflammatory cervical disorders
- B831. Carcinoma in situ of cervix uteri
- Click on the OK button to accept the recall record and return to the Cervical Cytology – Update screen.
- Click on the OK button to accept the cytology record.