Ob-Gyn Risk Alliance



BRCA Genetic Testing Checklist[Practice Name]Date___/__/_____________________________________________________________/____/_______ Patient Name (please print)Patient DOB______________________________________________________________________PhysicianMR #PRE-BRCA TESTING Checklist YesNoThe patient has been screened using current BRCA genetic screening criteria and has been determined to have an increased chance of having a BRCA genetic mutation.List risk factors:1. _________________________________________________________________________________2. _________________________________________________________________________________3. _________________________________________________________________________________Discussed with the patient information which may include but is not limited to the following: YesNoPurpose of the testBenefits of the testRisks of the testLimitations of the testThe meaning of a positive test resultThe meaning of a negative test resultThe meaning of an unclear/inconclusive test resultThe potential emotional, financial and social implications of test resultPrivacy protections and access to resultsCost of genetic testing and insurance preauthorizationAnticipated test turn-around-time _____________ days Referral to geneticistGeneticist name: __________________________________BRCA genetic testing patient education information providedInformed consent process is documented in the medical record and consent form is signedInformed refusal process is documented in the medical record if patient declines testing[Insert other information][Insert other information]Patient would like test results disclosed to them via:Phone ____ In-person ___Referred to: ___________________________ Referral follow-up: _____________(Specialist/Geneticist Name)(Date)Test results sent to ____________________________ LabDate sent ___/ ____/ ________ ________________________________________________________/____/______Signature of person completing this portion pre-testing checklist(Completion date)Post-BRCA Test ChecklistYesNoNABRCA test results are present in the medical recordBRCA 1/BRCA 2 positive patient referral(s) made and documented in the medical recordPatient counseled regarding test results documentedPatient educations documentedReferred to: ___________________________ Referral follow-up: ____/ ____/_____(Specialist/Geneticist Name)(Date)_____________________________________________________ ____/____/______Signature of person completing this portion post-testing checklist (Completion date) ................
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