How to document suspicious vs. non-suspicious CBE findings in WWC

Non-suspicious (normal) includes:

• Benign exam- clinical breast exam (CBE) findings are not a concern for cancer (tenderness, cyclic pain, or fibrocystic may fall into this category)
• Normal or negative exam
• Discrete lump, previously diagnosed as benign. Non-suspicious lumps should still be included in documentation since this is helpful in evaluating change or lack of change at future visits.

Suspicious or abnormal includes:

• Discrete palpable lump (suspicious)
• Bloody, clear or serous nipple discharge
• Nipple or areolar scaliness, rash or color change
• Skin dimpling or nipple retraction
• Inflammation 
• Suspicious breast pain (non-cyclic or pain/tenderness determined by provider to need further diagnostics)

All clients with an abnormal CBE finding should be referred for further diagnostic testing. The provider should indicate whether or not, based on the CBE and patient report, they would like to see additional diagnostics in cases of breast pain or tenderness. If the provider recommends further diagnostic testing in these cases, the CBE results should be documented as “suspicious."