Reproductive Health Access Project
Progestin Implant Removal Note
(PATIENT NAME) requests removal of their Etonogestrel rod implant (Implanon/Nexplanon). They would like it removed because of: (ABNORMAL BLEEDING/DESIRES PREGNANCY/ DUE FOR REMOVAL/SIDE AFFECTS/OTHER). The implant (WAS/WAS NOT) placed at (CLINIC NAME).
An informed consent was signed prior to removal and will be scanned into the Electronic Health Record. Risks of the procedure include: bleeding, infection, scarring, and nerve damage. There may be bruising at the site of incision and down the arm.
Procedure Note:
Time out taken: (TIME)
Team: (NAMES)
(PATIENT NAME) (PATIENT DOB) confirmed (YES/NO)
Procedure: Progestin Implant Removal
Procedure confirmed by patient and team (YES/NO)
Side: (RIGHT/LEFT)
Position correct for procedure (YES/NO)
Equipment for procedure available (YES/NO)
The patient took the supine position. Aseptic conditions were maintained. The rod was located by palpation. The area was cleaned with antiseptic. (NUMBER) cc of 1% lidocaine with epinephrine was injected just underneath the end of the implant closest to the elbow. After firmly pressing down on the end of the implant closer to the axilla a 2-3 mm incision was made with a scalpel. The rod was pushed to the incision site and grasped with a mosquito forceps and gently removed. Blunt dissection (WAS/WAS NOT) needed. The patient (DID/DID NOT) tolerate the procedure well. The 4 cm rod was removed in its entirety. The incision was dressed with small steri-strips and a pressure dressing was applied.
An alternate plan for contraception was discussed, if needed. The patient would like to use (CONTRACEPTIVE METHOD) for their contraception. An after-visit summary was printed with information about this method.
(PROVIDER NAME AND TITLE)
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