RN to Dispense Plan B, One Dose and No Refills

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:

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