Steps:

1. Consider the need to have a 3rd party present in the examination room.
2. Prepare the environment (padded stirrups, pillow, room temperature, poster/pictures).
3. Prepare the equipment (have tray ready, containers labels).
4. Prepare the patient (empty bladder, drapes/gowns, obtain pertinent patient history, discuss concerns including hstory of abuse).
5. Position the patient.
6. Explain the procedure.
7. Don gloves.
8. Warm metal speculum/lubricate/check temperature of instrument.
9. Seat yourself facing the patient's perineum.
10. Warn your patient about impending touch and potential discomfort.
11. Examine the external genitalia.
12. Insert speculum slowly and gently.
13. Locate cervical os.
14. Open speculum slowly to whatever degree patient can tolerate.
15. Screw metal speculum into place, click plastic speculum in open position or hold partially open with non-dominant hand.
16. If necessary, remove debris from cervical os with cotton swab.
17. Perform Pap.
18. Complete wooden spatula sampling of the exocervix adjacent to the os (360 degrees) and apply in a thin film with stroking motion to half or full non-frosted surface of pre-labeled glass slide.
19. Insert bristles of cytobrush as fully as possible into cervical os.
20. Rotate brush at least 1/4 turn in same direction.
21. Remove the cytobrush from os and apply sample in a thin film along the long axis of the non-frosted surface of glass slide as you rotate the bristles simultaneously.
22. Spray sample slide(s) with fixative.
23. If using liquid-based cytology, insert longer, central bristles of plastic "broom" into endocervix and rotate 5 times in same direction, allowing the shorter bristles to sample exocervix.
24. Remove the brush portion of the sampling instrument from handle with thumb and drop into specimen vial.
25. Cap vial tightly.
26. Place vial or slide into appropiate containers to transport to lab.
27. Sample endocervix for Chlamydia and Gonorrhea using cotton swab and place in appropiate media.
28. Swab vaginal vault if required.
29. Release and slowly remove speculum while inspecting vaginal wall.
30. Perform bimanual examination by gently inserting 2nd and 3rd appositioned fingers into introitus and gradually advancing them towards the cervix (or insert index finger in vagina and middle finger into rectum for rectovaginal examination).
31. Check for cervical motion tenderness.
32. Place the non-dominant hand on the patient's abdomen below the umbilicus, gradually moving down towards the suprapublic area.
33. Palpate the uterus between both hands, check for position, size, tenderness and contour.
34. Check the adnexa for tenderness and masses.
35. Discard disposible items with universal precautions and sterilize non-disposible equipment.
36. Arrange appropriate follow-up to inform patient of results.