III. MEDICAL DOCUMENTATION

Medical documentation is fundamental to patient care, follow up, and risk management. Customizing your electronic health record (EHR) or forms to allow quick and thorough documentation will help with successful integration of abortion or EPL care into your practice.The main forms that you will need include: informed consent, treatment or procedure note, and aftercare instructions. Ensure that all forms utilize gender inclusive language. Examples and templates of chart forms are available at RHAP and TEACH and through NAF for members.

1. Informed Consent

The goal of informed consent is to assure that the patient’s decision is voluntary and informed and to obtain legal permission for the procedure. Informed consent is a process, not just signing a form. It is an opportunity to establish a relationship with your patient, explore their understanding of the procedure, answer questions, and ensure the decision is their own (See Ch 2: Counseling and Informed Consent).

For medication abortion or EPL management with mifepristone, the patient must sign specific consent forms (Patient Agreement Form) from Danco or GenBioPro as part of the REMS regulations.

For telehealth medication abortion, consents can be signed electronically. For patients who do not have easy internet access, consent may also be done in person or by mail.

2. Pertinent Patient Care Notes

For medication abortion or medication management of EPL, verify and document the following:

• Pertinent health history including allergies
• Confirmation of pregnancy (by home or clinic urine pregnancy test, serum hCG or US)
• Gestational duration by clinical dating or ultrasound (if performed)
• As needed lab testing
  • Rh testing and immune globulin (if indicated, see Ch 3)
  • Hemoglobin or hematocrit (if indicated, see Ch 3)
• Confirmation of patient phone number
• Confirmation that patient has the 24-hour number to reach the clinic for concerns
• Plan for pain management
• Plan for follow-up visits as needed, and whether it will be in person, telehealth or an on-line follow-up survey
• Choice of post-abortion contraception, if desired (may be required by insurer to document in a separate note)
• Mifepristone and misoprostol lot numbers and expiration dates (as applicable)
• Be cautious that visits may be visible across state lines within the same EHR system (e.g. Epic). Although some systems have taken steps to protect abortion-related information, not all issues have been addressed.  Certain states have laws requiring sensitive services to be segregated from the rest of the chart.

For telehealth medication abortion:

• The documentation is the same as listed above. It will also be helpful to document the date and time frame in which the medications will be delivered. Some mail order pharmacies will want to know a 2-4 hour timeframe in which the patient will be home to deliver the medications.

For uterine aspiration for abortion or EPL management, you should also include:

• For EPL management especially in legally restrictive settings confirmation of the EPL (i.e. US or blood work)
• A documented “time-out”  confirming patient identity, procedure, allergies, and relevant medical history
• Pre- and post-procedure vital signs
• Time (e.g. start and end of procedure, medications given)
• Physical exam, as needed (i.e. vitals, bimanual, and speculum findings)
• Tissue exam results
• Comments section—special findings or problems
• A comment on patient’s tolerance to procedure and recovery course
• Medications given for pain management, bleeding, or antibiotic prophylaxis
• Estimated blood loss
• Complications, if applicable
• Referrals and follow-up visits, if needed

In addition to the standards you already follow for medical charting, here are some things that may be pertinent to abortion care:

• Document who assisted in the procedure
• Record vitals +/- who took them
• Use non-judgmental statements in records
• Have ultrasounds signed off by the provider, unless performed by another licensed clinician or radiologist
• As above, be cautious that visits may be visible across state lines within the same EHR system (e.g., Epic) so document only what you need to know for clinical care. Although some systems have taken steps to protect abortion-related information, not all issues have been addressed. Currently it is not illegal for people to travel to a state where abortion is legal, however, criminalization risks remain.

Questions and documentation that should be avoided include:

• Whether the patient used medicines or other means to initiate bleeding.
• The circumstances surrounding their pregnancy, who they discussed their decision with, or if they received any assistance.
• Information about their pregnancy, abortion decision, or potential assistance from others, particularly if those questions are intended for law enforcement or to determine guilt.

For discharge after uterine aspiration procedures, ensure you have documented the following:

• Patient is ambulatory
• Bleeding and pain are controlled
• Patient understands instructions outlining signs and symptoms of post-abortion complications and after-hours contact number
• Post-procedure vital signs
• Choice of post-abortion contraception, condoms, and emergency contraception, if desired

3. Aftercare Instructions

Include the following in your written aftercare instructions:

• What to expect (cramping, bleeding)
• Symptoms of possible complications (fever, severe cramps, heavy bleeding)
• After-hours phone number
• Follow-up plan
  • Aspiration procedures—follow-up is not needed.
  • Medication abortion (including telehealth options)—Provide UPT with a recommendation to check after 5 weeks. A follow-up may be offered in person or by televisit 1-2 weeks after medication abortion, although many patients decline or no show.

See Chapter 4 for medication abortion aftercare instructions and Chapter 6 for uterine aspiration aftercare instructions.

• Medication Abortion Aftercare Instructions
• MVA Procedure Aftercare Instructions
• Post Abortion Self-Care

4. Follow Up Considerations

Following medication abortion, documentation can include confirmation of abortion completion.  This can be accomplished by a) clinical history in conjunction with urine pregnancy test; b) serum hCG trend, orc)  ultrasound. Clinical charting should indicate that the patient and provider are confident the pregnancy has passed (i.e. expected bleeding and cramping course, resolution of pregnancy symptoms) and a negative home pregnancy test 5 weeks after completing the medication abortion.

Following aspiration abortion, most patients can be given aftercare instructions and a phone number to call with concerns, in lieu of a routine follow-up visit (Grossman 2004). If a patient reports heavy bleeding, signs of infection, or it is unclear whether the pregnancy has passed, an in-person evaluation is warranted.