Title: / Dispensing Plan B / Number:
Activation Date: / Review due by:
Sponsoring/Contact Person(s) / Dr. Nicole M. Nitti MD CCFP(EM)
Order and/or Delegated Procedure: / Appendix Attached: Yes No Title:
  • RN to dispense Plan B, one dose and no refills

Recipient Patients: / Appendix Attached: Yes No Title:
  • All primary care clients of Access Alliance including off-site locations

Authorized Implementers: / Appendix Attached: Yes Title: List of Implementers
Health care providers at Access Alliance with the following designation:
  • RN

Indications: / Appendix Attached: Yes No Title:
  • Female client age 16 or greater who has had unprotected sex within the last 120 hours
  • Client experiences financial barrier to purchasing this medication at a pharmacy
** If client is less than 16 years of age to be put in for same day visit with NP or MD (ideally primary care provider if available)
Contraindications: / Appendix Attached: Yes No
  • Client with a known pregnancy
  • No consent from Client or substitute decision maker
  • Implementer not knowledgeable about the medication
  • Client/Chart reports allergy or significant reaction to the medication
  • Client is taking a medication that has a harmful interaction with Plan B
** If client has any contraindications, RN to refer client to a NP or MD for same day visit (ideally primary care provider if available)
Guidelines for Implementing the Order / Procedure: / Appendix Attached: Yes No Title:
  • Complete Appendix 1: Screening form for Plan B
  • Label medication with patient name, prescriber name, name of med, directions of use, and number of tablets and date dispensed (label to be visibly placed on container)
  • Implementer to explain directions of use, reason for use and review side effects with patients using language and cultural interpretation if required

Documentation and Communication: / Appendix Attached: Yes No Title:
  • Appendix 1: Screening form for Plan B to be completed and scanned into the patient chart
  • RN to document prescription for medication under PLAN->MEDICATION
  • The prescription must include dose, frequency and amount
  • Client should be instructed to take the dose immediately and informed that the sooner it is taken after unprotected intercourse the greater the effectiveness. Plan B is most effective when taken with the first 72 hours after unprotected intercourse.
  • In PLAN, text box to include “Client advised to follow up with Primary Care Provider if does not have menses within 3 weeks after taking Plan B or if client develops lower abdominal pain or persistent irregular bleeding after taking Plan B”
  • RN to book client in with Primary Care provider for follow up re: birth control. Indicate in section “Follow up”
  • Under services provided: click box “medication dispensing”

Review and Quality Monitoring Guidelines: / Appendix Attached: Yes No Title:
Competency review check list
  • All medical directives to be reviewed annually by medical director and signed by all staff physicians

Administrative Approvals (as applicable): / Appendix Attached: Yes No Title:
Approving Physician(s)/Authorizer(s): / Appendix Attached: Yes Title: Authorized Physician signatures