Medication Abortion Charting Form printable pdf download

Medication Abortion Charting Form

Patient Name:

Chart Number:

MEDICATION ABORTION CHARTING FORM

Yes

N/A

Options counseling documented

Adverse effects explained

Protocol explained:

Timing of medications

Need for follow-up visit

On-call system

Contraindications ruled out: No IUD in place

No allergy to

prostaglandins/mifepristone No chronic adrenal failure

No long-term systemic corticosteroid

No concurrent anticoagulant therapy

No ectopic pregnancy

No hemorrhagic disorder

Mifeprex medication guide given

Mifeprex provider/patient agreement signed

Informed, evidence-based consent form signed

Rh status (circle one):

Positive

Negative

Rhogam given (if indicated)

Initial beta-HCG level: ____________

Hemoglobin level _______________

Ultrasound dating done

Pain medication prescribed

Mifeprex lot number recorded: ____________date administered:

Follow-up visit completed on: _____________________

Abortion completion assessed by: History

Beta-HCG level

Sonogram

Medication Abortion Charting Form