Electronic Health Record Template

Electronic Health Record Template:

Manual Vacuum Aspiration (MVA) for miscarriage

Patient Name: {patient name}

MRN: {MRN}

DOB: {DOB}

SUBJECTIVE

{patient name} is a {xx} year old, coming today for for treatment for her miscarriage. We discussed her options at length, including expectant management, medication management with misoprostol, manual vacuum aspiration, or referral for a procedure elsewhere with sedation. She has decided that she would prefer a manual vacuum aspiration in our office. She is accompanied today by her{companion:315061}.

Her miscarriage was diagnosed by {Miscarriage management:11732}.

OBJECTIVE

.VS (vital signs) with pain

{general appearance:5021}

{PELVIC EXAM:709}

Ultrasound Exam: gestational sac, yolk sac, fetal pole give a gestational age of ***. A copy of the sonogram is in our log.

Patient Namesigned the consent, it is to be scanned into the record.

Procedure:

Time out taken : {time}

Following information identified:

Patient: Patient Name

Procedure: manual vacuum aspiration

Site: (location and laterality): vagina, cervix, uterus

A sterile speculum is placed.

A probe for GC/Chlamydia {WAS/WAS NOT:9033} obtained.

A pap smear {WAS/WAS NOT:9033} obtained.

The cervix and vagina were swabbed with betadine.

Lidocaine, total 20cc, was injected to provide a paracervical block.

The tenaculum was placed at12 o'clock. The cervix was progressively dilated to *** with the Dennniston dilators. An IPAS cannulae size *** was inserted and the uterine contents were aspirated.

There were {BLEEDING:111066}. The procedure was {COMPLICATED:9078}. The tissue exam {WAS/WAS NOT:9033} complete. A post procedure ultrasound {WAS/WAS NOT:9033} indicated and {WAS/WAS NOT:9033} done.

Reaspiration {WAS/WAS NOT:9033} indicated and {WAS/WAS NOT:9033} done.

The patient tolerated the procedure well.

The post procedure vital signs were taken and noted by nursing and reviewed by me.

ASSESSMENT:

Patient Nameis now status post a Manual vacuum Aspiration, has been observed for 30 minutes and is stable to leave the office.

PLAN:

I have given her the post MVA for miscarriage handout detailing what to expect post procedure.

She is aware to call for fever, pain or abnormal bleeding.

Her birth control options were discussed and the orders were placed for {CONTRACEPTION:706}.

Folic acid {was/was not:9033} recommended.

An Rh typing{WAS/WAS NOT:9033} sent.

A quantitative Beta hcg {WAS/WAS NOT:9033} indicated and {WAS/WAS NOT:9033} sent.

Patient Namehas been asked to follow up at the appropriate interval for her periodic well woman exam.