MEDICATION ABORTION CHART FORM

Date: ______________

LMP: ______________    Regular   Y____ N____

Was using contraception?   Y____ N____

Previous pregnancies ________________________________________________

Hx ectopic pregnancy          Y____ N____

Allergies: _______________________        Blood type: _____________________

Contraceptive preference: ____________     

Patient phone numbers    Home: _______________       Work: ________________   

                                       Cell: _________________      Other: ________________

 

Physical Examination    Ht.                Wt.                  BP                     P

Speculum exam ____________________________________________________

Bimanual exam __________________________________      Adnexal mass   Y/ N

Estimated gestational age __________      Consistent with dates Y____ N____

Sonogram indicated   N ____ Y____ (reason) ______________________________

 

Counseling

_______ Has received patient education materials, instruction sheet, and contact information

_______ Has agreed to treatment and has signed patient agreement

 

Treatment

MD initials Medication dispensed and/or prescribed LPN initials
  Mifepristone 200 mg  PO in office  lot# ___  exp.date __/__  
 

Misoprostol 200 mcg.  lot# ______     exp.date ___/___
4 tabs given to patient for buccal use at home on __/__/__

 
 

Pain Rx:  Ibuprofen 400 mg 1 or 2 q 4-6-h prn pain     #100
              Vicodin (5 mg hydrocodone/500mg APAP)        #10
Other: ________________________________         # __

 
  Rhogam IM in office  
  EC prescribed  Plan B _________________    # of refills___  
  Contraceptive  ______________________    # of refills___  

______ DOH form completed and sent

Signed: ___________________________________

 

Serial labs and tests

Date Urine HCG Serum HCG Hct/Hgb Ultrasound Other
           
           
           
           

Pain during procedure (1-10) ___________________________________________

Pain Medication(s) used _______________________________________________

_________________________________________________________________

 

Follow-up Visits and Calls

Date Notes (sign each one)

 

Final Disposition

____MTOP successful; contraception prescribed ______________________________

____ MTOP unsuccessful   ___ Referred for suction on _____ Suction done _____

____ Continued pregnancy; enrolled in prenatal care

____ Lost to follow-up

         Signed: ___________________________________         Date: ___________