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.
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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