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Document a clinical encounter in the patient record

Learner Task: Write a procedure note for the IUD insertion.
Educator Reference: See sample procedure note and follow up below:

  • Procedure Note: Patient desires long-term, reversible contraception. Informed consent was obtained. Timeout procedure was performed to ensure correct patient and correct IUD. A bimanual exam was performed to determine the position of the uterus. The speculum was placed. The vagina and cervix was sterilized in the usual manner and sterile technique was maintained throughout the course of the procedure. A single toothed tenaculum was applied to the anterior lip of the cervix and gentle traction applied to straighten and stabilize it. The depth of the uterus was sounded to be of appropriate depth (usually 6.5 to 8.5 cm). With gentle traction on the tenaculum, the IUD was inserted to the appropriate depth and deposited by withdrawing on the insertion tube holding the rod steady. The string was cut to an estimated 4 cm length. Bleeding was minimal. Hemostasis achieved. The patient tolerated the procedure well without complications.
  • Follow-up: Standard post-procedure care was explained and return instructions were given.

Educator Checklist: IUD Procedure Note
Mark the appropriate column to indicate whether the learner included each element in his or her response. When completed, tally the “Included” column to calculate the learner’s score.

Included =1 Not Included =0
Explains the purpose of procedure
Informed consent
Timeout and patient verification
Physical examination: writes about at least two of the following: uterine size, position and depth of sound
Identifies at least two of the following tools utilized: speculum, tenaculum, sound
How IUD inserted, string cut
Follow-up (precautions, return appointment)