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Urine Pregnancy Test Ordering- Adult/Pediatric – Ambulatory [113]

Urine Pregnancy Test Ordering- Adult/Pediatric – Ambulatory [113] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Ambulatory Delegation Protocols




Delegation Protocol Number: 113

Delegation Protocol Title:
Urine Pregnancy Test Ordering – Adult/Pediatric – Ambulatory

Delegation Protocol Applies To:
Adult and pediatric patients seen in UW Health Primary Care, General Pediatric and OB/Gyn Clinics

Target Patient Population:
Female patients ages 12 – 55 years

Delegation Protocol Champions:
Kathy Oriel, MD - Department of Family Medicine - General
David Rabago, MD - Department of Family Medicine – General
Kristin Lewicki, MD - Department of Internal Medicine
Laura Sabo, MD - Department of Obstetrics/Gynecology
Paula Cody, MD – Department of Pediatrics - GPAM

Delegation Protocol Reviewers:
Elizabeth Kolk, RN, MBA – UWHC Internal Medicine – Women’s Health
Jenny Accola, RN, BSN – Clinic Coordinator - UW OB/GYN
Susan Golz, LPN – Family Medicine – Northeast Clinic

Responsible Department:
Department of Family Medicine
Department of Internal Medicine
Department of Obstetrics/Gynecology
Department of Pediatrics

Purpose Statement:
This protocol delegates authority from Providers to Registered Nurses (RNs), Licensed Practical Nurses (LPNs),
and Medical Assistants (MAs) to place orders for urine pregnancy testing for female patients being seen for
select indications.

Who May Carry Out This Protocol:
RNs, LPNs, and MAs who are trained in the use of this delegation protocol.

Guidelines for Implementation:
1. This protocol is initiated for any of the following:
1.1. Prior to the following procedures:
1.1.1. Endometrial biopsy
1.1.2. Colposcopy
1.2. Contraception
1.2.1. Prior to initiation of any pharmacologic contraceptive method
1.2.2. Prior to intrauterine device (IUD) placement unless another IUD is being removed concurrently
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org



1.2.3. Prior to treatment with medroxyprogesterone acetate suspension(DepoProvera, Depo-SubQ
Provera) if more than 15 weeks have elapsed since the previous injection
1.2.4. Prior to placement of etonogestrel (NEXPLANON)
1.3. Possible Pregnancy
1.3.1. Prior to first OB visit
1.3.2. Patient expresses concern they may be pregnant
1.4. Prior to visit for any female patient age 12 years to 50 years reporting irregular or heavy menstrual
cycles
2. This protocol does not apply to the following situations where pregnancy can be reasonably excluded:
2.1. Age younger than 12 years or older than 55 years
2.2. Status post hysterectomy or removal of both ovaries
2.3. Miscarriage or abortion within the last 7 days
2.4. Patient has given birth in the past 4 weeks
2.5. Patient is menopausal.
3. To avoid duplicates staff will review the medical record to determine if testing has already been ordered. If
not previously ordered, clinic staff will enter an order for HCG, Qualitative (Pregnancy).


Order Mode: Cosign Required, Protocol/Policy

References:
1. Feltmate CM, Feldman S. Colposcopy. In: UpToDate, Goff B (Ed), UpToDate, Waltham, MA. (Accessed on
March 28, 2015.)
2. Carusi DA, Goldberg AB. Insertion and removal of an intrauterine contraceptive device. In: UpToDate,
Zieman M (Ed), UpToDate, Waltham, MA. (Accessed on March 28, 2015.)
3. Nexplanon [package insert]. Whitehouse Station, NJ: Merck & Co; 2014
4. Centers for Disease Control and Prevention (CDC). U.S. Selected practice recommendations for
contraceptive use, 2013. 2
nd
ed. MMWR Morb Mortal Wkly Rep. 2013;62(RR05):1-46.
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6205a1.htm?s_cid=rr6205a1_w . Accessed March 28,
2015.

Collateral Documents/Tools: NA

Approved By:
UW Health Ambulatory Protocol Committee: April 2015
UW Health Laboratory Practice Committee: April 2015
UW Health Center for Clinical Knowledge Management Council: June 2015
UWHC Medical Board: July 2015
UW Health Chief Ambulatory Medical Officer: July 2015

Effective Date: July 2015

Scheduled for Review: July 2017
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org