Patient Name - Reproductive Health Access Project
MVA PROCEDURE NOTE
Date:
Physical Examination:
Uterus: Size in weeks (bimanual): ______ AV/Mid / RV
Cervix: WNL / CMT, parous/nullip
Vagina: WNL / discharge noted:
Procedure:
□ Pap done: gc, chlam done:
□ Cervix and vagina swabbed with Betadine.
□ Lidocaine 1%, _________cc total injected.
□ Tenaculum applied _________ o’clock.
□ Cervix progressively dilated to: _________.
□ Cannula inserted, size __________.
Estimated blood loss: ________ cc.
Additional comments:
Tissue Exam:
□ Decidual tissue
□ Villi
□ Gestational sac
□ Tissue appropriate for gestational age
Post-Op Ultrasound if done:
□ No IUP visualized Other:
Assessment:
□ Patient stable, AB complete
□ Pad checked for bleeding
For complications, see progress notes
□ Post-procedure vital signs:
B/P____ P____
Plan:
□ Expected symptoms discussed; post-procedure instructions given.
□ Rhogam if needed:_______________
□ Doxycycline 100 mg tabs 2 tab _______ Dispensed or ___ 1 gm Zithromax
□ Contraception: _________________________________________________
□ Follow up appointment recommended.
Clinician Signature: ___________________________________________________
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