Chart Review Form: Aspiration Abortion |
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Yes |
No |
N/A |
| Options counseling 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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| Sonogram documented |
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| Hemoglobin level documented |
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| All medication use documented |
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| Contraception plan documented |
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| Gonorrhea and Chlamydia done |
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| Induced termination of pregnancy form done |
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| Post-op instructions reviewed with patient |
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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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