Appendix 2 (page 1 of 2)
Emergency Hormonal Contraception (EHC) Patient Group Direction (PGD)
Checklist
Client’s name (optional) _____________________________________
The following information must be completed:
Age/DOB _______________
Full postcode _______________
Date of Consultation _______________
Before EHC is offered complete the following checklist
Tick
Determine reason for request for emergency hormonal contraception
Check exclusion criteria in PGD





UPSI since LMP (> 72 hours ago and EHC not taken in last 12
hours)
EXCLUDE PREGNANCY
U 16 (not Fraser competent)
Hypersensitivity to progestogens or any ingredient
Does the client have breast cancer?
Does the client have severe liver disease?
Rare hereditary problems of glucose/galactose metabolism,
severe malabsorption states
Are any medicines being taken, including prescription and nonprescription medication, to ensure no exclusion?
Estimate likely date of ovulation and risk of pregnancy by recording:
Client’s History
Date of first day of LMP______________________ day of cycle___________
Length of normal menstrual cycle _________
Was LMP in any way abnormal? Yes / No
Hours since condom accident /unprotected sex _____________
Timing of all inadequately protected intercourse (including any missed pill history and intercourse
during a lengthened pill-free interval) – which day(s) of the current cycle?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
If EHC was given for any previous episodes of unprotected intercourse this cycle, which and
when ____________________________________________________
Result of pregnancy test if performed (if LMP was missed altered)
Positive / Negative / Not done
Appendix 2 (page 2 of 2)
COUNSELLING
Yes
Mode of action, Side effects and risks discussed
Possible effects on foetus discussed & possible effects on menstrual
cycle.
Effectiveness including failure rate discussed
Discuss future contraception and if appropriate arrange for the next cycle
Give relevant client leaflet, FPA leaflet and manufacturer’s product
information within the pack.
Discuss the need to abstain from sexual intercourse or use of a barrier
method correctly and consistently for the remainder of the current
menstrual cycle as EHC does not provide contraceptive cover for the
remainder of the cycle
Advise of the possibility of an ectopic pregnancy if the method should fail
Discuss safe sex, breast awareness, cervical screening and other health
promotion issues
Clients under the age of 16 years must be counselled / assessed using
Fraser Guidelines
Check client’s understanding of the method, and willingness to use
Dose taken on premises
Summary
Less than 72 hours since first episode of unprotected intercourse
Explain method options, to include the better efficacy of an IUD and the fact
that EHC is not as effective as conventional, regular use of hormonal
contraceptives and is suitable only as an emergency measure
Discuss future contraception – LARC and risk of STIs
Signpost for LARC (GP/CASH)
Client prefers and accepts hormonal method
Supplied: Levonelle® 1500 microgram tablets
(1500 micrograms Levonorgestrel)
Batch number
No
Tick
Yes / No (Advice only)
Expiry date _______________
Referred to GP / CASH for LARC/ Yes / No
Action Taken:
The above information is correct to the best of my knowledge. I have been counselled on the
use of emergency contraception and understand the advice given to me by the Pharmacist.
Clients Signature: _____________________________ Date _____________
The action specified was based on the information given to me by the client, which, to the best
of my knowledge, is correct.
Name of Pharmacist ___________________________ Date _____________
For those signed up to offering clients Chlamydia testing kits, please discuss this
issue if the patient meets the inclusion criteria as per the SLA.