Learning and Development,

Departments & Programs,UW Health,Ambulatory Education,Ambulatory Orientation,Checklists - Core and Department Specific,Resources

Gynecology and Urogynecology

Gynecology and Urogynecology - Departments & Programs, UW Health, Ambulatory Education, Ambulatory Orientation, Checklists - Core and Department Specific, Resources


GYNECOLOGY & UROGYNECOLOGY- CLINICAL TRAINING CHECKLIST ----- This is due three months from hire date------

Employee Name: __________________________________ Employee Credentials:________ Hire Date: ____________

Clinic Location/ number: _______________________ Employee Number ________________________

*** N/A on checklist indicates that it is not indicated for the employee***
*Refer to appropriate UWMF Policy ***Each area should either be discussed or observed by preceptor***

AREA OF ORIENTATION Discussed Observed Preceptor’s Signature Completed date
GYN Intake Interview –
Employee is able to gather data on or identify:

Menstrual history
Family planning issues
Teen pregnancy
Sexual concerns
Expedited partner therapy
History-health management, social, and family
Current medications, dosages to patient’s understanding
Physical signs/symptoms of domestic abuse
Psychosocial health status when indicated
Patient ’s perception of problem (if appropriate)
Patient’s expectations in medical care (if appropriate)
Patient’s knowledge level/deficit (if appropriate)
Cultural practices related to care
Information regarding relationships with significant others
Appropriate resources for gaps in family support structure

GYN Heath Education – Employee is able to discuss with patient:
Demonstrate breast self-exam
Contraceptive options, including use, effectiveness, risks and benefits of each method
Proper exercise program, or be able to obtain information
Proper nutrition program, or be able to obtain information
Infertility program, or be able to obtain information
Pre-conceptual counseling program, or be able to obtain information
Prevention/treatment of sexually transmitted diseases, or be able to obtain information
Normal and abnormal PAP tests, or be able to obtain Information
Is able to discuss with patient abnormal bleeding, or be able to obtain information

AREA OF ORIENTATION Discussed Observed Preceptor’s Signature Completed date
Employee is able to gather data relevant to the following:
Evaluation of incontinence
Signs and symptoms urinary frequency or urgency or urinary infections
Signs and symptoms hematuria or retention
Evaluation of incontinence
Signs and symptoms of interstitial cystitis
Patient's history of Kegel exercises

GYN - Employee is able to discuss with patient:
Special needs of adolescent/pediatric gyn patient, or be able to obtain information
Special needs of perimenopausal & postmenopausal pt, or be able to obtain information
Hormone replacement therapy, or be able to obtain information for patient
Stress incontinence and uro-gynecological issues, or be able to obtain information
Malignant tumors of breast or reproductive tract

Telephone Triage - Employee is able to appropriately conduct triage calls:
Employee is able to appropriately assess triage calls into the clinic
Conduct telephone triage with appropriate assessment questions and telephone triage
tools (protocol book)

Appropriately call back and use appropriate telephone techniques
Appropriately fill out the telephone call documentation requirements utilizing smart tools
within Health Link as available

Appropriately refill medication refill request via the telephone
Actively listens and asks appropriate questions
Team Leader review documentation of 10 triage calls within first month looking for
completeness, disposition, and documentation

Review HIPPA and telephone calls; leaving a voice message

Demonstrate competence to assist/set-up/patient care/follow-up:

Endometrial biopsy
Labial, vulvar and cervical biopsies
Lesion removal
Cytology and Cultures
Staple removal
Abnormal bleeding or shock during a procedure
IUD insertion

AREA OF ORIENTATION Discussed Observed Preceptor’s Signature Completed date
Implanon insertion / removal
Urine Dip
Bladder Scanner
Proper and complete labeling of specimens and paperwork

Employee is able to obtain the following:
ξ Oral Temperature (if used in clinic)
ξ Pulse Rate – radial and apical*
ξ Respirations*
ξ Blood Pressure*
ξ Orthostatic BP and P*
ξ Pulse Oximeter*
ξ Adult Weight/Height*

Medication Adm. - employee will demonstrate a minimum of two injections per
category listed below using the corresponding UWMF policy. Preceptor will initial
blank when completed.

o Adult >18 years: subcutaneous* _________ & __________
o Adult >18 years: intramuscular* _________ & __________

Surgery - Employee is able to:
Schedule surgery of patient appropriately
Obtain pre-authorization for surgery
GYN Surgical Checklist
Different Surgery Packets
Information required for the Surgery Packets

Sterilization of Instruments/Autoclaving
Assures instrument cleaning and autoclaving is properly completed
Assures proper wrapping and marking of packs
Assures proper cleaning of autoclave

AREA OF ORIENTATION Discussed Observed Preceptor’s Signature Completed date
Provides URGENT Patient Care – Employee is able to:
Appropriately cares for patients in an emergent or urgent situation utilizing the various
Emergency Delegation Management Protocols (found in the Emergency Procedure manual
in the department)
ξ Anaphylactic
ξ Cardiac
ξ Seriously Ill or Unstable
ξ Hypoglycemia
ξ Pulseness Non-Breathing (PNB)
ξ Seizure

Administration of Immunizations and other medications: Consults EH/IC when there
are questions

Appropriately performs TB testing and reading *
Uses appropriate VIS handouts for each immunizations
Uses imm/injection section in HealthLink for documentation in addition to
.npwimmscreen in the progress note area of HealthLink

Appropriately understands and performs immunizations for Mumps, Measles and
Rubella, Tdap or combinations of the same components, Hepatitis B, and HPV; others as

Properly documents administered medications
Properly disposes of expired medications
Properly disposes of unused or discarded or refused medications

Demonstrates knowledge of medication refills

Online Training: utilize the Learning and Development system (LDS)

LDS Course name: Depo-provera Injection Training for new staff – to be completed by
any staff person who will be administering Depo-provera.

Administration of Medications: Understands the following drug compatibility

Analgesics: aspirin, , ibuprofen, acetaminophen, Demerol, Tordal, Midol, morphine,
Percocet, etc

Antacids: Alka-seltzer, Maalox, Mylanta, Rolaids Anti-emetics: Compazine, Zofran,

Antibiotics: amoxicillin, ceftriaxone, cefazolin, gentamicin, penicillin, tobramycin,

Anti-diarrheals: Imodium, Kaopectate, Pepto-bismol

AREA OF ORIENTATION Discussed Observed Preceptor’s Signature Completed date
Antihistamines: Loratadine ,Benadryl, Comtrex, Dimetapp, Dristan, Sudafed
Anti-pyretics: acetaminophen, ibuprofen
Diuretics: bumex, lasix
Decongestants: Afrin, Benadryl
Expectorants: Robitussin, Sudafed
Laxatives: Colace, MOM, metamucil, peri-colace
Monophasic Contraception: Orthocyclen, Mircette, Levlen
Triphasic Contraception: Orthotricyelen
Anti-neoplastic: methotrexate
Hormones: Estrogens, Progesterone (Depo-Provera)* , Lupron
Provide patient education about: Vaginal creams, suppositories, and douches


I, _________________________________________ (employee name) have completed the GYN/UROGYN Clinical Training Checklist and attest the information is true and
valid. I have demonstrated or discussed these skills and I am responsible for performing patient care as a Certified Medical Assistant / Licensed Practical Nurse / Registered Nurse
(circle one).

__________________________________________________ ___________________
Preceptor Date

____________________________________________________ ___________________
Supervisor Date

__________________________________________________ ___________________
Provider Date

Additional Preceptor Signatures/initials:
1. _________________________________________________
2. _________________________________________________
3. _________________________________________________
4. _________________________________________________

Initially Completely 7.22.2014, 3.1.2017
 Send the original signed CLINICAL TRAINING CHECKLIST to Clinical Staff Education – 1035.
 One copy of the signed CLINICAL TRAINING CHECKLIST should be placed in the clinic’s staff employee’s file, and a copy given to the employee.

Kowalak, J. P. (Ed.). (2009). Lippincott’s nursing procedures (5th ed.). Ambler, PA: Lippincott Williams & Wilkins.
Perry, A.G. & Potter, P.A. (2009). Fundamentals of nursing. (7th ed.). Hall, A. & Stockert, P.A. (Eds.). St. Louis, MO: Mosby Elsevier.
MO: Mosby Elsevier.