Pregnancy concern

Template

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Confidential interviewChoose any

ResultChoose one

SafetyChoose any

Plan for a positive testChoose anyNot in the note with these choices

Plan for a negative testChoose anyNot in the note with these choices

Follow-upChoose one

CounselingNot in the note with these choices

The decision belongs to the patient, with the support the patient chooses, and care stays confidential. Recommended supportive care with an emphasis on avoiding alcohol, smoking, vaping, and drugs, and attending the next visit. Return precautions given including heavy bleeding, severe belly or shoulder pain, dizziness or fainting, severe vomiting, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Patient expressed understanding and agreement with plan. Answered all questions.

CounselingNot in the note with these choices

Recommended supportive care with an emphasis on condoms and a reliable birth control method. Return precautions given including a missed period, pelvic pain, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Patient expressed understanding and agreement with plan. Answered all questions.

Counseling

Return precautions given including heavy bleeding, severe belly pain, a missed period, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Patient expressed understanding and agreement with plan. Answered all questions.

Note when inserted as is

Pregnancy concern
• Confidential time with the adolescent, with the limits of confidentiality reviewed
• Follow up in 1 week

Return precautions given including heavy bleeding, severe belly pain, a missed period, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Patient expressed understanding and agreement with plan. Answered all questions.

What the sources cover

All options counseling (parenting; adoption, kinship, foster; abortion)
Prenatal vitamin, prenatal care referral
Facilitated abortion referral
Involving a parent or trusted adult (documented)
Negative: contraception, repeat test, EC

Return precautions in the template

heavy bleedingsevere belly or shoulder paindizziness or faintingsevere vomiting

Sources

This template was built from clinical practice; no source is linked yet.