Chart Review Form: Medication Abortion |
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Yes |
No |
N/A |
| Options counseling documented |
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| Adverse effects education documented |
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| Protocol explanation documented |
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| Informed consent form: In chart |
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Labeled
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Signed
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| Rh status documented |
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| Rhogam given (if indicated) |
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| Initial Beta-HCG level documented |
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| Hemoglobin level documented |
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| Pain medication prescribed |
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| Follow-up visit completed |
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Assessment of abortion completion documented:
History
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Beta-HCG level
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Sono
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| Contraception plan documented |
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| Pap smear result documented (if applicable) |
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Gonorrhea and Chlamydia results documented
*Appropriate treatment offered (as indicated) |
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These forms are not intended to provide legal, medical or other professional advice. They are not a substitute for consultation with a healthcare provider or for independent judgment by healthcare providers or other professionals regarding individual conditions and situations. |
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