Checklist for Breast Examination(To be completed by the Trainer)

Place a in case box if step/task is performed satisfactorily, and if it is not performed satisfactorily, or N/O if not observed.
Satisfactory: Performs the step or task according to the standard procedure or guidelines
Unsatisfactory: Unable to perform the step or task according to the standard procedure or guidelines
Not Observed: Step or task or skill not performed by participant during evaluation by clinical trainer
PARTICIPANT______ / Date Observed______
CHECKLIST FOR BREAST EXAMINATION
STEP/TASK / CASES
GETTING READY
  1. Greet the woman respectfully and with kindness.
/ X / X / X / X / X
  1. Tell the woman you are going to examine her breasts.
/ X / X / X / X / X
  1. Ask the woman to undress from her waist up. Have her sit on the examining table with her arms at her sides.
/ X / X / X / X / X
  1. Wash hands thoroughly and dry them. If necessary, put on new examination or high-level disinfected surgical gloves on both hands.
/ X / X / X / X / X
BREAST EXAMINATION
  1. Look at the breasts and note any differences in:
  • shape
  • size
  • nipple or skin puckering
  • dimpling
Check for swelling, increased warmth or tenderness in either breast. / X / X / X / X / X
  1. Look at the nipples and note size, shape and direction in which they point. Check for rashes or sores and nipple discharge.
/ X / X / X / X / X
  1. Look at breasts while woman has hands over her head and presses her hands on her hips. Check to see if breast hang evenly.
/ X / X / X / X / X
  1. Have her lie down on the examining table.
/ X / X / X / X / X
  1. Look at the left breast and note any differences from the right breast.
/ X / X / X / X / X
  1. Place pillow under woman’s left shoulder and place her arm over her head.
/ X / X / X / X / X
  1. Palpate the entire breast using the spiral technique. Note any lumps or tenderness.
/ X / X / X / X / X
  1. Squeeze the nipple gently and note any discharge.
/ X / X / X / X / X
  1. Repeat these steps for the right breast. If necessary, repeat this procedure with the woman sitting up and with her arms at her sides.
/ X / X / X / X / X
  1. Have the woman sit up and raise her arm. Palpate the tail of the breast and check for enlarged lymph nodes or tenderness.
/ X / X / X / X / X
  1. Repeat this procedure for the right side.
/ X / X / X / X / X
  1. After completing the examination, have woman cover herself. Explain any abnormal findings and what needs to be done. If the examination is normal, tell the woman everything is normal and healthy and when she should return for a repeat examination.
/ X / X / X / X / X
  1. Show the woman how to perform a breast self-examination.
/ X / X / X / X / X

PARTICIPANT IS ___ QUALIFIED___ NOT QUALIFIED TO PERFORM BREAST EXAMINATION BASED ON THE FOLLOWING CRITERIA: