Medication Abortion Charting Form —
Charting Form for Medication Abortion with Mifepristone |
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Patient Name: __________________________
Chart Number: __________________________ |
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N/A |
| Options counseling documented |
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| Adverse effects explained |
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Protocol explained:
Timing of medications
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Need for follow-up visit
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On-call system
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Contraindications ruled out:
No IUD in place
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No allergy to prostaglandins/mifepristone
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No chronic adrenal failure
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No long-term systemic corticosteroid tx
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No concurrent anticoagulant therapy
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No ectopic pregnancy
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No hemorrhagic disorder
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| Mifeprex medication guide given |
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| Mifeprex provider/patient agreement signed |
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| Informed, evidence-based consent form signed |
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| Rh status (circle one): Positive / Negative |
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| Rhogam given (if indicated) |
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| Initial beta-HCG level: ____________ |
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| Hemoglobin level ____________ |
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| Ultrasound dating done |
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| Pain medication prescribed |
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Mifeprex lot number recorded:
____________date administered: |
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| Follow-up visit completed on: ____________ |
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Abortion completion assessed by:
History
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Beta-HCG level
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Sonogram
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| Contraception plan reviewed |
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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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