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 care into your practice.

The main forms that you will need include: informed consent, operative or procedure note, medications, discharge note, aftercare instructions, and follow up visit. Consider having a fact sheets that compares medication vs. aspiration abortion, contraceptive options and emergency contraception (RHAP). Examples and templates of all chart forms are available in Office Practice Tools. In this section, we will review important points to include in staff training.

INFORMED CONSENT

In Chapter 2: Counseling and Informed Consent, you will find information to review and train your staff about the counseling and informed consent issues specific to uterine aspiration for abortion or miscarriage. Even if they are never formally counseling or obtaining consent, it is important for staff understand the process – because they have contact with patients that the provider does not. Staff should feel empowered to bring any concerns to the provider’s attention (such as witnessing an overbearing partner telling a patient they must “go through with this”).

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.

PROCEDURE NOTES

For medication abortion, document and verify:

  • Pertinent medical history
  • Confirmation of pregnancy (by urine hCG or US)
  • Gestational age by clinical dating or ultrasound results (if performed)
  • Rh testing and immune globulin, if indicated (NAF CPGs 2016)
  • Hemoglobin or hematocrit (if indicated)
  • Abortion success (by POC exam, history, US, and / or hCG fall from baseline)
  • Choice of post abortion contraception, if de, unless required by insurer to document in a separate note

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

  • Pertinent medical history review
  • Allergies, specifically including latex, iodine, shellfish, and medications.
  • Physical exam, as indicated
  • Pre and post procedure vital signs
  • Time (e.g. start and end of procedure, medication given)
  • Tissue exam results
  • Comments section – special findings or problems
  • A comment on patient’s tolerance to procedure
  • Medications given for pain control, bleeding, or antibiotic prophylaxis
  • Estimated blood loss
  • Referrals and follow-up visit, if applicable

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
  • Sign off ultrasounds by the provider, unless performed by another certified clinician or radiologist
  • Document any changes in patient status during recovery (e.g. patient states, “I feel dizzy.”)

For medication abortion, you should also include:

DISCHARGE NOTES

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 op vitals following the procedure
  • Choice of post abortion contraception, if desired.

AFTERCARE INSTRUCTIONS

For examples, see Chapter 6 for uterine aspiration aftercare and Chapter 7 for medication abortion aftercare. Include the following in your written aftercare instructions:

  • What to expect (cramping, bleeding)
  • Symptoms of possible complications (fever, severe cramps, heavy bleeding)
  • Limitations, as needed (exercise, bathing, heavy lifting, sex) – no evidence
  • After hours phone number
  • If, and when, to return for follow-up

WORKING WITH INTERPRETERS

For your patients that speak limited or no English, use the resources for interpretation that you already use in your practice. Utilizing bilingual staff or professional interpreter services are best, although telephone interpreter services have become more readily available in many languages. These resources should provide basic and accurate language skills, neutrality and confidentiality. If you must rely on a friend or family member, be sensitive to these limitations.