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, 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.
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 Chapter 2: Counseling and Informed Consent)
For medication abortion or EPL management with mifepristone, the patient must sign specific consent forms from Danco or GenBioPro as part of the REMS regulations.
For telemedicine medication abortion, consents can be signed electronically. For patients who do not have easy internet access, consents may also be done in person or by mail.
2. Pertinent Patient Care Notes
For medication abortion or medication management of EPL, document and verify:
- Pertinent medical history including allergies
- Confirmation of pregnancy (by urine pregnancy test, b-hCG or US)
- Gestational age by clinical dating or ultrasound (if performed)
- As needed lab testing
- Confirmation of patient phone number
- Confirmation that patient has a 24 hour number to reach provider/clinic for urgent concerns
- Plan for pain management
- Plan for follow up visit, and whether it will be in person or televisit
- 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
For telemedicine 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:
- A documented “time-out”
- Pre- and post-procedure vital signs
- Time (e.g. start and end of procedure, medication given)
- Physical exam (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 control, bleeding, or antibiotic prophylaxis
- Estimated blood loss
- Complications, if applicable
- Referrals and follow-up visit, 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 initials by each set of vitals
- Use non-judgmental statements in records
- Have ultrasounds signed off by the provider, unless performed by another certified clinician or radiologist
For discharge after uterine aspiration procedures, assure you have documented that:
- 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, 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) – follow up may be done in person or by televisit 1-2 weeks after medication abortion.
See Chapter 4 for medication abortion aftercare instructions and Chapter 6 for uterine aspiration aftercare instructions.
4. Follow Up Considerations
Following medication abortion, documentation should include confirmation of success of medications. This can be accomplished by clinical history, serum hCG trend, or ultrasound. Clinical history should indicate that the patient and provider are confident pregnancy has passed (ie 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 not clear that pregnancy has passed, then an in-person evaluation is warranted.