Smart text name: “.options”

Description: Text for the note needed for an initial visit to prepare for a first trimester abortion. This text includes the requirements for the Pennsylvania Abortion Control Act and must be completed at least 24 hours before an abortion in Pennsylvania. Below the text are the labs that must be ordered unless the results are already available. This note is structured to allow a level IV visit with >50% of time spent in counseling.

.name is a .age year old woman who presents today to discuss options for her pregnancy. Patient had a positive pregnancy test *** which we confirmed today. She has *** periods and her LMP is *** which puts her at an estimated gestational age of *** weeks and *** days. The patient has had *** previous pregnancies with *** deliveries, *** induced abortions, and *** early pregnancy losses (miscarriages). The patient reports using *** contraception at the time that she became pregnant. She states that this is an unplanned pregnancy and she needs to discuss her options. She is considering induced abortion. The father of this pregnancy *** involved and *** present for this session.

.Allergy

.PMH

.Med

.SOC

.VS

Gen: Patient is well appearing and in no acute distress

HEENT: MMM, no oral e/e/l

Cor: RRR, no M/R/G

Review of data:

*** ultrasound is available. ***

Recent CBC is *** available ***

Blood type is *** known ***

Counseling: Patient was provided the counseling required for the PA Abortion Control Act. Briefly this includes: 1) letting her know that there are alternatives to abortion including adoption, 2) Insurance is available for prenatal care as well as pediatric care if the baby were to be born, 3) The father of the baby can be forced to help support the child financially, and 4) that there is a book of pictures of fetal development that can be seen if she wishes but it is not required.

The patient chose *** to view this book of photographs.

We also discussed post abortion contraception and reviewed the IUD as well as other choices that she might make. She understands that these options are all appropriate and safe after abortion.

A/P: Patient is a G***P*** woman with no contraindications to abortion. After discussing her options she desires a termination of pregnancy in our office. She understands that she can choose to have a medical abortion up to 9 weeks of gestation or a manual vacuum aspiration up to 12 weeks of gestation. The patient was taken to the front desk and scheduled for this procedure in the next available procedure session with Dr. Martin, Dr. Reed, or Dr. Bennett on ***. I have also sent a message to this provider to let them know about this patient.

.diag

.timestamp

Labs that should be ordered if not already available

CBC

Blood Type (Rh)

If the patient is interested in a Manual vacuum aspiration she should be told to take 2 alleve tablets (400mg) or 600 mg of Ibuprophin 30 minutes before coming into the office.