Pharmacy EHC Scheme
Emergency Hormonal Contraception
PROFORMA
for use by Pharmacists working with Herefordshire PCT Patient Group Direction
Pharmacists - Please refer to the full PGD for all the information – this is intended only as an aide memoire.
Reason for EC: UPSI Condom Failure Previous supply & Vomiting/Diarrhoea Missed COC Missed POP other……………………………………………If missed COC – where in packet? (see appx 2)…………………………………………………………………....
Date of UPSI……………………………... time………………...…. Hrs since UPSI (specify hrs) ……………
Other UPSI this cycle – date………………………. Other EHC this cycle – date…………………….
Problems with EHC?. .…………………………………………………………………………………………………
Menstrual History
1st day of LMP_____/_____/_____usual cycle: ____/____ (e.g. 5/28)Day in cycle of UPSI…………………… Possibility of Pregnancy (from previous UPSI) Yes/No
Pregnancy test recommendedYes/NoPregnancy test performedYes/No Test result…………….
Under 16 years old
Fraser Judgement (Gillick competence)– assessed satisfied Yes/ Not Applicable(see appx 1 for details)
Decision to refer Y/N Notes…………………………………………………………………………………………………………………….
Medical History Multiple use of emergency contraception in this cycle Yes/No
Serious Liver Disease/Porphyria Yes/No Severe malabsorption syndromes e.g. Crohns Disease Yes/NoAny relevant current medication……………………………………………………………………………….
Taking Enzyme Inducing DrugsYes/No (see PGD for details: 2 packs of Levonelle-2– double dose instructions )
Action TakenContraceptive & Sexual Health Services Co-ordinator Tel 01432 378979 (9am-5pm)
If >72 hours; pregnant; multiple EHC (>2/cycle); does not want EHC,refer to GP/ClinicSide effects/Failure rates discussed Anti-emetic recommended
Advise pregnancy test if period more than 7 days late Advised on visiting GP/Clinic
Protection for rest of cycle discussed Future Contraception discussed
Advice and leaflets:…….. Clinic Times STIs fpa Contraception
Reasons for choosing pharmacy for advice/supply √ (please choose the most applicable.)
1. No appointment necessary. 2. Access – opening hours convenient. 3. Anonymous service. 4. Referred by practice.5. Referred by Gaol St. 6. Referred by other pharmacy. 7. Word of Mouth. 8. Previous Client.
9. Other (please specify)……………….………………………………………………
Levonelle-1500 issued:No of packs issued ……..
Submit copy of completed forms with monthly invoice to HPCT Finance Dept, 1st Floor, Plough Lane, Hereford, HR4 0LE Version 2 November 2010