MVA QI CHART REVIEW FORM

  Yes No N/A
Options counseling documented      
Informed consent form:   In chart      
                                      Labeled      
                                      Signed by patient, provider,
                                      and witness
     
Rh status documented      
Rhogam given (if indicated)      
Sonogram documented (if needed)      
Hemoglobin level documented      
All medication use documented      
Contraception plan documented      
Procedure note in chart      
Gonorrhea and Chlamydia done      

Induced Termination of Pregnancy form completed
(if required by state law)

     
Post-op instructions reviewed with patient