Name________________________________ Class ________ Date___________ Time_________
Pt. Requests: ECP Preg Test
S:___________________________________________________________________________________
Yes No Description
| LMP Normal | every ___________days Gravida_____________ Para________________ | ||
| Contraceptive use | Method? | ||
| Nausea | |||
| Dizziness | |||
| Vomiting | |||
| Frequent Urination | |||
| Fatigue | |||
| Breast Tenderness | |||
| Alcohol use | |||
| Consensual act? |
| Ovulation date | LMP date _________/_______/_______ Calculated ovulation date ________/________/_______ |
| Unprotected inter. | Date _____/_____/_____ Time ________________ AM PM Unknown |
| Last previous inter. | Date _____/_____/_____ Time ________________ AM PM Unknown |
Current meds ______________________________________________________________________________________
Allergies: _________________________________________________________________________________________
Patient Concerns ___________________________________________________________________________________
O: HCG not done HCG done. Results : Pos Neg 1st a.m. specimen Yes No
Exam performed Exam
not done
| temp___ | WNL | ABN | |
| appear | |||
| back/CVA | |||
| Abd |
| ext.genit | |||
| speculum | |||
| bimanual |
Positive HCG - options counseling offered Negative HCG - contraception information offered HCG not done
P: Criteria not met for ECP RTC for HCG with 1st am specimen
Post coitial contraception as per situation Consent form signed Packet with info given
Lo Ovral 4 white pills now p.o. followed by 4 white pills 12 hrs. later.
Ovral 2 white pills now p.o. followed by 2 white pills 12 hrs. later
Triphasil (yellow pills only) 4 now p.o. followed by 4 yellow pills only 12 hrs. later.
Other Rx______________________________
Benadryl 25 mg.. po Or Phenergan 25 mg. po ½ hr. prior to oral contraceptives.
Other antiemetic agents _____________________________________________
Refer to Counseling Center
Prevention counseling Refer
to outside agency
__________________________________________________________________
Provider
Criteria for ECP
ECP must be given within 72 hrs. after unprotected intercourse.
Unprotected intercourse must have been from 3 days before until 3 days after ovulation.
Ovulation occurs 14 days prior to next menses usually.
ECP is prescribed for unprotected intercourse during that time interval,
plus one day on each end.
ECP should be provided to women with irregular menses throughout their cycle
because ovulation is unable to be calculated with any certainty.