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Primary Care Physician
20-25 minutes

Guidance on Birth Control Template

The Contraception Counseling template by s10.ai is expertly crafted for General Practitioners and nurses to meticulously document patient interactions concerning contraceptive choices. This template encompasses sections for medical history, gynecological history, family history, lifestyle factors, and patient preferences, ensuring a holistic approach to patient care. It thoroughly addresses various contraceptive methods, including hormonal contraceptives, barrier methods, IUDs, permanent solutions, and emergency contraception. By capturing all pertinent information, this comprehensive template supports informed decision-making and personalized care. Perfect for primary care environments, it streamlines the documentation process, enhancing efficiency and thoroughness for healthcare professionals.

3,522 uses
4.6/5.0
D
Dr. Emily Chen
Template Structure

Organized sections for comprehensive clinical documentation

Patient Name: [Patient’s Name] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Date of Birth: [DOB] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Date of Visit: [Date] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Medical Record Number: [MRN] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Visit Type: Contraceptive Consultation
History and Background:
Presenting Complaint: [Presenting Complaint] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Medical History:
- Chronic Conditions: [List any chronic conditions such as diabetes, hypertension, etc.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Previous Contraceptive Methods Used: [e.g., hormonal pills, condoms, IUD, etc.], [Provide details about patient’s experience with each method] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Allergies: [List any known allergies] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Medications: [List current medications and any relevant interactions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Gynaecological History:
- Menstrual History: [Describe regularity, any abnormalities] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Sexual Activity: [Note frequency, partners, any concerns] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Pregnancy History: [Number of pregnancies, outcomes, any complications] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Family History:
- Reproductive Health: [Any family history of reproductive health issues] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Chronic Diseases: [Relevant family history] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Lifestyle Factors:
- Smoking Status: [e.g., Non-smoker, Smoker (details if applicable)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Alcohol Use: [e.g., Social drinker, None, etc.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Physical Activity: [e.g., Sedentary, Regular exercise, etc.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Patient’s Preferences and Concerns: [Patient’s Preferences and Concerns] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Contraceptive Options Discussed:
choose from options below
1. Hormonal Contraceptives:
- Birth Control Pills: [Discuss effectiveness, side effects, and need for daily adherence] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Contraceptive Patch: [Discuss application, effectiveness, and possible skin reactions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Depo-Provera Injection: [Discuss frequency of injections, side effects] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
2. Barrier Methods:
- Condoms: [Discuss use, effectiveness, and additional benefits like STI prevention] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
3. Intrauterine Devices (IUDs):
- Copper IUD: [Discuss non-hormonal, long-term use, possible menstrual changes] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Hormonal IUD: [Discuss hormonal effects, duration, and potential side effects] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
4. Permanent Methods:
- Sterilization: [Discuss permanency, procedure details, and consideration for future fertility] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
5. Emergency Contraception:
- Options Available: [Discuss when to use, effectiveness, and accessibility] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Advice Given:
- Method Selection: [Method Selection] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Usage Instructions: [Usage Instructions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Follow-Up: [Follow-Up] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Emergency Contraception: Provided information on emergency contraceptive options in case of contraceptive failure or unprotected intercourse.
Patient Education Materials Provided: [Patient Education Materials Provided] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Signature:
[Provider’s Name] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
[Provider’s Title] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
[Provider’s Contact Information] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Date: [Date of Documentation] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Sample Clinical Note

Example of completed documentation using this template

Patient Name: Jane Doe  
Date of Birth: 01/01/1990  
Date of Visit: 10/10/2023  
Medical Record Number: 123456  
Visit Type: Contraception Counselling  
History and Background:  
Presenting Complaint: Seeking guidance on long-term contraceptive options.  
Medical History:  
- Chronic Conditions: None  
- Previous Contraceptive Methods Used: Hormonal pills (caused nausea), Condoms (no issues)  
- Allergies: None  
- Medications: Daily multivitamin  
Gynaecological History:  
- Menstrual History: Regular cycles, no abnormalities  
- Sexual Activity: Active, monogamous relationship  
- Pregnancy History: 1 pregnancy, full-term, no complications  
Family History:  
- Reproductive Health: No known issues  
- Chronic Diseases: Mother has hypertension  
Lifestyle Factors:  
- Smoking Status: Non-smoker  
- Alcohol Use: Social drinker  
- Physical Activity: Regular exercise  
Patient’s Preferences and Concerns: Prefers a long-term, low-maintenance contraceptive method.  
Contraceptive Options Discussed:  
1. Hormonal Contraceptives:  
   - Birth Control Pills: Discussed effectiveness, side effects, and need for daily adherence  
   - Contraceptive Patch: Discussed application, effectiveness, and possible skin reactions  
   - Depo-Provera Injection: Discussed frequency of injections, side effects  
2. Barrier Methods:  
   - Condoms: Discussed use, effectiveness, and additional benefits like STI prevention  
3. Intrauterine Devices (IUDs):  
   - Copper IUD: Discussed non-hormonal, long-term use, possible menstrual changes  
   - Hormonal IUD: Discussed hormonal effects, duration, and potential side effects  
4. Permanent Methods:  
   - Sterilization: Discussed permanency, procedure details, and consideration for future fertility  
5. Emergency Contraception:  
   - Options Available: Discussed when to use, effectiveness, and accessibility  
Advice Given:  
- Method Selection: Patient interested in Hormonal IUD  
- Usage Instructions: Provided detailed instructions on IUD usage  
- Follow-Up: Scheduled follow-up in 3 months to assess satisfaction and any side effects  
- Emergency Contraception: Provided information on emergency contraceptive options in case of contraceptive failure or unprotected intercourse.  
Patient Education Materials Provided: Brochure on Hormonal IUDs  
Signature:  
Dr. s10.ai  
General Practitioner  
555-123-4567  
Date: 10/10/2023
Clinical Benefits

Key advantages of using this template in clinical practice

  • The Contraception Counselling clinical template is an essential tool for healthcare providers seeking to deliver comprehensive and personalized contraceptive care. This template is designed to streamline the documentation process, ensuring that all critical aspects of a patient's medical, gynecological, and family history are meticulously recorded. It facilitates a thorough discussion of various contraceptive options, including hormonal methods, barrier methods, IUDs, and permanent solutions, tailored to the patient's unique preferences and health considerations. By adopting this template, clinicians can enhance patient engagement, improve decision-making, and ensure adherence to best practices in reproductive health management. Explore this template to optimize your clinical workflow and elevate the quality of care provided to your patients.
Frequently Asked Questions

Common questions about this template and its usage

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Guidance on Birth Control | Medical Chart Template