Physical Examination:

Uterus: Size in weeks (bimanual): ______ AV/Mid / RV
Cervix: WNL / CMT, parous/nullip
Vagina: WNL / discharge noted: _____________________________________

Procedure:

Pap done_________ gc, chlam done ___________
Cervix and vagina swabbed with Betadine.
Lidocaine 1%, _________cc total injected.
Tenaculum applied _________ o’clock.
Cervix progressively dilated to: _________
Cannula inserted, size __________

Estimated blood loss: ________ cc.
Additional comments:_____________________________________________

Tissue Exam:

Decidual tissue
Villi
Gestational sac
Tissue appropriate for gestational age

Post-Op Ultrasound if done:

No IUP visualized Other: ____________________________________

Assessment:

Patient stable, AB complete
Pad checked for bleeding
      For complications, see progress notes
Post-procedure vital signs:
       B/P____ P____

Plan:

Expected symptoms discussed; post-procedure instructions given.
Rhogam if needed:_______________
Doxycycline 100 mg tabs 2 tab ____ Dispensed or ____ 1 gm Zithromax
Contraception: ___________________________________________
Follow up appointment recommended.

Clinician Signature: _______________________________________________