MEDICATION ABORTION QI CHART REVIEW FORM

  Yes No N/A
Options counseling documented      
Adverse effects education documented      
Protocol explanation documented      
Patient Agreement form: In chart      
                                      Labeled      
                                      Signed by patient and provider      
Rh status documented      
Rhogam given (if indicated)      
Initial Beta-HCG level documented      
Hemoglobin level documented      
Pain medication prescribed      
Follow-up visit completed      
Assessment of abortion completion documented:
                                      History
     
                                      Beta-HCG level      
                                      Sono      
Contraception plan documented      
Pap smear result documented (if applicable)      
Gonorrhea and Chlamydia results documented
*Appropriate treatment offered (as indicated)