Record of individual consultation for supply of progestogen only emergency
contraception under community pharmacy PGD
Date:
Time:
Client details
Name:
Address:
Postcode:
Date of birth:
Registered GP:
Current medication:
Current conditions:
Confidentiality Discussed
Yes/No
Reason for client requesting consultation for EHC
Please give a brief summary of reason:
Consultation outcome
EHC required:
YES/NO
If no, please state reason why and advice given:
MEDICINE SUPPLIED
Levonorgestrel
YES/ NO
BATCH NUMBER:
EXPIRY DATE:
YES/ NO
BATCH NUMBER:
EXPIRY DATE:
YES/ NO
BATCH NUMBER:
EXPIRY DATE:
1500mcg tablet
Levonelle
(Schering)
Upostelle
(Consilient)
If no please state reason why it was not supplied, the advice given and action taken:
Name of Pharmacist:
GPHC number:
Pharmacist Signature:
Date:
Inclusion and exclusion criteria
Refer if NO to one of more of the following
Unprotected sex/contraception failure within last 72 hours:
Yes/No
First episode (only occasion) of UPSI since last menstrual period:
Yes/No
Vomited within two hours of ingestion of first supply of EHC:
Yes/No
13 years old or over:
Yes/No
If under 16 years of age and fulfils Fraser guidelines:
Yes/No
Refer if YES to one or more of the following:
1
Not present in person
Yes/No
Previously taken EHC within current cycle
Yes/No
Experiencing diarrhoea/vomiting:
Yes/No
21 days or less post-partum (if applicable)
Yes/No
Last period unusually light, heavy or missed@
Yes/No
One or more contra-indications to Levonelle: (severe liver dysfunction, malabsorption
Yes/No
syndromes, known hypersensitivity to Levonorgestrel or any of the ingredients of the
product. Acute porphyrias, severe liver disease, Gastric bypass surgery (with exception
of gastic band). Ulipristal administered within previous 9 days. Experiences previous
severe clinical problems with POEC (excluding nausea).
Taking other medications that significantly interact with EHC:
Yes/No
Likely to be pregnant
Yes/No
Advice provided (tick box if advice relevant and provided
Oral and IUD Methods:
Yes/No
Mode of action:
Yes/No
Efficacy / failure rate:
Yes/No
Dose / how to take;
Yes/No
Side- effects:
Yes/No
Risk of ectopic pregnancy:
Yes/No
Actions to be taken if abdominal pain or heavy bleeding:
Yes/No
Actions to be taken if vomiting occurs within two hours:
Yes/No
Timing of next period (early, late or usual):
Yes/No
Contraception advice (immediate or remainder of cycle):
Yes/No
Contraceptive advice (future or longer term):
Yes/No
Condom use discussed
Yes/No
Risks of sexually transmitted disease / advice:
Yes/No
Information on sign posting to Sexual Health service (Telephone 0333 000 0014)
Yes/No
Chlamydia screening testing kit issued (not all people have symptoms): ACTIVITY
Yes/No
FUNDED
IF DECLINED TEST REASON WHY:
□ No change of partner since last test
□ Not Sexually Active
□ Tested elsewhere
□ No reason given
□ Not enough time since last test
□ Not appropriate
□ N/A Test Given
Inform GP if taking warfarin (with patients consent)
C Card scheme offered (ACCREDITED PHARMACIES ONLY (13-24 of age);
Yes/No
ACCEPTED C CARD (complete C Card Paperwork)
Yes/No
IF DECLINED C CARD REASON WHY: □ Over 24years old
contraception
□ No reason given
□ Previous use of EHC □ Consent to treat
2
□ Alternative method of