Whole Woman’s Health of [City] 9999 Street Name, Suite z, City, State Zip local number : 800 number Surgical Abortion Record Patient: _____________________________________D.O.B___________________Date: ________________________ Pre-op Evaluation: LMP date: __________ Normal / Abnormal Est gestational weeks: _________ IUP: _________ U/S Tech: _________ G: _____ P: _____ SAB: _____ TAB: ______ Last Delivery Date: __________ Vaginal or Cesarean Problems: __________ BP:______/______ Pulse:________ Temp:________ Wt:________ Rh Factor:_______ Hgb:_____Hct:_____ Lab Tech:____ UCG: __________ HCG: ___________ ALLERGIES: ________________________________________________________ Reason for no abortion: _________________________________________________________________________________ Date: ________ BP:_____/_____ Pulse:_______ Temp:_______ Wt:_______ Lab Tech:______ IUP:______U/S Tech:______ Ibuprofen Phenergan Tylenol Dosage 800mg 25/50mg 500 mg Route PO PO/IM/IV PO Time ______ ______ ______ Initials ______ ______ ______ Xanax/Ativan Misoprostol Amoxicillin Dosage Route .5/1/ 2 mg PO ___mcg Buc/Vag/PO ______ IV/IM/PO Time ______ ______ ______ Initials ______ ______ ______ Contraceptive medication of patient’s choice at doctor’s discretion. Medication selected/given: _____________________ Surgical Assist IV Set-up: The patient was brought to the procedure room, was prepped and draped in the usual manner for pelvic surgery. Site:_____ # of Attempts:_____ Gauge:_____ Type:_____ DC’d Intact @:_____ IV Solution:_____ Nitrous Oxide: Start time: _____ -- at standard 50/50 mix, or _____% Initials: _____ End time: _____ Initials: _____ Time Pulse Oximeter Blood Pressure Respirations LOC Initials _______ _________ ____________ ____________ ____________ ____________ _______ _______ _________ ____________ ____________ ____________ ____________ _______ _______ _________ ____________ ____________ ____________ ____________ _______ _______ _________ ____________ ____________ ____________ ____________ _______ Physical Examination / Procedure: The physician has evaluated the patient for risks for anesthesia. _________ ( M.D. Initials) Medications Administered: Dosage Route Time Initials Dosage Route 2.0mg IV/IM ______ ______ 10mg IV/IM Versed Nubain IV/IM ______ ______ 50/100mcg IV/IM Atropine 0.4mg Fetanyl 10/20 u IV/IM ______ ______ Methergine 0.2 mg IV/IM Pitocin 10/20 mg IV/IM ______ ______ Mini/Full CX/IM Valium Rhogam ________ ________ IV/IM _______ ______ ________ ________ IV/IM Time ______ ______ ______ ______ ______ Initials ______ ______ ______ ______ ______ Procedure Start Time: __________ Procedure End Time: __________ HEENT: _______________________________________ Lungs: ________________________________________ Thyroid: _______________________________________ Abdomen: _____________________________________ Heart: _________________________________________ Lams In: _______________ Lams out: _____________ Uterine Sound: ___________ Canula Size: 5 6 7 8 9 10 11 12 13 14 16 Uterine Size: 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Position: ant / st / retro / kc Uterine injection (paracervical: 1% lidocaine 20cc / 5cc na bicarb w/ vasopressin) Time per MD: _______________ First trimester vacuum aspiration. D&E procedure, product was emptied from the uterus in multiple fragments. Fetal demise caused by ________________. Fetal demise confirmed before the pregnancy was removed from the uterus. Product emptied from uterus and taken to path lab. Patient was taken to Aftercare in good condition. Time:__________________ MD Initials:____________ Assistant Initials:____________ M.D. notes: __________________________________________________________________________________________ ____________________________________________________________________________________________________ Physician Signature: ___________________________________________________________________________________ Revised Feb. 2010 AHM. Reviewed Feb. 2012- AF. Updated for HB-2 October, 2013-AF. 1 Whole Woman’s Health of [City] 9999 Street Name, Suite z, City, State Zip local number : 800 number Post Abortion Observation Name: _____________________ Date: _________ Time in: ______ Discharge Time: ______ Vital Signs Temp: ______ Time Pulse B/P LOC Cramping ____ ____ ____ ____ none / mild / moderate / severe ____ ____ ____ ____ none / mild / moderate / severe ____ ____ ____ ____ none / mild / moderate / severe Bleeding: Nil / Scant / Minimal / Moderate / Heavy Initials _________ _________ _________ Medication administered Description Dosage Route Time Initials Atropine 0.4mg IM / IV _____ _____ Phenergan 25mg PO / Supp / IM _____ _____ Pitocin 10/20u IM _____ _____ Methergine 0.2mg PO / IM _____ _____ Narcan / Naloxone 0.4mg IV / IM _____ _____ Romazicon 0.2mg IV / IM _____ _____ Depo Provera 150mg IM _____ _____ Flumazenil _____ IV / IM _____ _____ Rhogam (full) Micrhogam (mini) YES NO Lot# ________________ Exp__________ Site: L/R deltoid L/R glut Discharge _____Doxycycline 100 mg bid # ______ _____ stable _____Naproxen 550 mg DS bid # _____ _____ ambulatory _____Methergine 0.2mg PO # _______ _____ voided _____Flagyl 1g stat dose PO # _______ _____ tolerated PO fluids _____ _______________ # _______ _____ tolerated PO solids RX filled at WWH Pharmacy OR RX given for outside pharmacy OR Meds issued by WWH WWH Med Label WWH Med Label WWH Med Label The following information has been discussed with the patient: _____ B/C options have been discussed with the patient and her method has been decided. _____The importance of a two-week follow-up appt has been discussed, and it has been scheduled. _____ The importance of an annual well woman exam has been discussed. _____ All the consent forms have been signed, and an ID or affidavit is on file. _____ The post-procedure care instruction sheet has been reviewed and given to the patient. _____ The patient has been informed to call if she experiences any problems. _____ The instructions on how to take her prescriptions were given to the patient. _____ Nearest hospital to her home: ______________________ Ph#___________ The physician has evaluated the patient for proper post-anesthesia recovery _______________ (MD Initials) I, ________________________________, have been informed of all information listed above. Patient Signature I, ________________________________, have discussed all information listed above. Aftercare Staff Member Comments / Notes: ____________________________________________________________ ____________________________________________________________ Revised Feb. 2010 AHM. Reviewed Feb. 2012- AF. Updated for HB-2 October, 2013-AF. 2