Supply of Levonelle 1500 under a Patient Group Direction

Record Sheet

Client name: / First part of postcode:
Date of birth / Age *

* If client is under 16 years of age you must ensure that an assessment of ‘Gillick competence’ is made during the consultation, and that the assessment form is completed and filed with this record.

Source of referral
(please circle) / Morley St / GP / Friend / Other (please specify)
Youth Service / School nurse
Date of consultation: / Time (24hr clock): / Day of week:
Reason for needing EHC (eg type of contraceptive failure, or no contraception used etc)
Date and time of unprotected sexual intercourse (UPSI)
Time elapsed since UPSI (hours)
Day 1 of LMP (last menstrual period)
Day of cycle today
Taking hormone method of contraception currently? / Yes / No
If yes, what type? (eg COC, POP, injection)
If missed pills, contraceptive patch problem, or overdue progestogen injection give details
If not on pill, shortest & longest cycle length
Previous emergency contraception since LMP? / Yes / No – details

Criteria for Inclusion - if ALL answers are “YES”

First episode of sexual intercourse without the use of effective contraception since day 1 of last normal period (or vomited previous EHC dose within 3 hours and still within 72 hours of only act of unprotected sexual intercourse this cycle) / YES / NO
Other options for EC discussed / YES / NO
Client prefers hormonal method / YES / NO

If all the answers here are ‘YES’, proceed to questions about exclusion criteria. If the client has answered ‘NO’ to any of the questions refer her to her GP or Family Planning Clinic.

Criteria for Exclusion – requires referral if any answers are “YES”

NOTES
Has client used any other form of EC this cycle? / YES / NO / (If client has received EHC but vomited does(s) refer to inclusion criteria above).
Is any interacting treatment being taken now, or within the last month? / YES / NO / (Refer to the current versions of the BNF and SPC).
Is the client taking warfarin or ciclosporin? / YES / NO / If yes, refer to GP.
Is it possible from the menstrual / sexual history that the client may be pregnant?
Does the client have an existing pregnancy? / YES / NO / Is the period late? Was the last period lighter or shorter than normal? Was the last period unusual in any way? Since the last period has the client had unprotected sex at any time before this time? Refer the client to Family Planning Clinic or GP for advice.
Have there been any episodes of unprotected sexual intercourse more than 72 hours ago in this cycle? / YES / NO / If yes, refer without delay. IUD may be appropriate.
Does client have liver disease / acute porphyria / or recent trophoblastic disease? / YES / NO / If yes, refer to GP.
Does client have severe malabsorption or chronic diarrhoea? / YES / NO / If yes, refer to GP as EHC may not be sufficiently absorbed.
Is the client allergic to any of the ingredients of Levonelle 1500? / YES / NO / If yes refer. IUD may be appropriate.
Does the client wish to see a doctor? / YES / NO / If yes refer to GP or Family Planning Clinic.
Client declines treatment. / YES / NO / Refer to GP or Family Planning Clinic, and document advice given.

Counselling

Tick to indicate you have covered the following (all need to be covered before continuing)

Mode of action discussed.
Failure rate discussed.
Side effects discussed (including symptoms of ectopic pregnancy).
Possible effects on foetus discussed.
Follow up discussed.
Future contraception discussed, including information about where services are located.
Has the 'safe sex pack' been given to the client?
Client advised to go to GP or family planning clinic 3 weeks after taking Levonelle 1500 (taking a urine sample if the expected period is delayed by more than a week or unusually light). A printed reminder is contained in the 'safe sex pack' provided to all clients under this scheme.
ACTION TAKEN:
Supply including batch number/expiry
Date (attach duplicate label here):
Supervised consumption?
YES / NO
Referral advice:
Advice given:

The information above is correct to the best of my knowledge. I have been counseled on the use of emergency contraception and understand the advice given to me

Client’s Signature: / Date:

The stated action was based on the information given to me by the client, which is correct to the best of my knowledge.

Issuer’s name: / Date:
Issuer’s signature:

Other Notes

Brighton and HoveCity Teaching PCT

Levonorgestrel PGD for Community Pharmacists

Record Sheet1 of 3Nov 07