MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES COMPLICATION REPORT FOR POST-ABORTION CARE 1a. Patient Number 1c. 1d. County 1e. City, Town or Location 1b. Date of 2. Date of Abortion (Mo., Day, Yr.) (Mo., Day, Yr.) PATIENT 3a. Facility Name 3b. Street Address 3c. City, Town or Location 3d. 3e. Type of Abortion Performed: FACILITY Surgical Medical ABORTION WAS (Non-surgical) PERFORMED 4a. Facility Name 4b. Street Address 4c. City, Town or Location 4d. State FACILITY REPORTING 5b. If Yes, Name of Facility 5c. Street Address 5d. City, Town or Location 5e. 5a. Was Patient Previously Seen at COMPLICATION Another Facility for Post-Abortion Care? Yes No 6. COMPLICATIONS (Please check one or more): 7. RESULT OF COMPLICATION: Incomplete Abortion Hysterectomy Hemorrhage Death of Woman Endometritis Transfusion Parametritis Other (Describe) Pyrexia Abscess, Pelvic 8. Was Patient Hospitalized? Yes No If Yes, Name of Hospital: Uterine Perforation Failed Abortion, Pregnancy Undisturbed Hospital Street Address: Retained Products Cervical Lacerations Hospital City, Town, Location Psychiatric – Other (Describe) 9b. Signature of Physician 9a. Name of Physician (Type or Print) 10. Date of This Post-Abortion Care (Mo., PHYSICIAN Day, Yr.) PROVIDING CARE MO 580-0353 (9-17) SCHS-8 (10-80)
MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES COMPLICATION REPORT FOR POST-ABORTION CARE PATIENT 1a. Patient Number 1b. Date of (Mo., Day, Yr.) 1c. 1d. County 1e. City, Town or Location 2. Date of Abortion (Mo., Day, Yr.) FACILITY ABORTION WAS PERFORMED 3a. Facility Name 3b. Street Address 3c. City, Town or Location 3d. 3e. Type of Abortion Performed: Surgical Medical (Non-surgical) FACILITY REPORTING COMPLICATION 4a. Facility Name 4b. Street Address 4c. City, Town or Location 4d. State 5a. Was Patient Previously Seen at Another Facility for Post-Abortion Care? Yes No 5b. If Yes, Name of Facility 5c. Street Address 5d. City, Town or Location 5e. 6. COMPLICATIONS (Please check one or more): 7. RESULT OF COMPLICATION: Incomplete Abortion Hysterectomy Hemorrhage Death of Woman Endometritis Transfusion Parametritis Other (Describe) Pyrexia Abscess, Pelvic 8. Was Patient Hospitalized? Yes No Uterine Perforation If Yes, Name of Hospital: Failed Abortion, Pregnancy Undisturbed Retained Products Hospital Street Address: Cervical Lacerations Psychiatric Hospital – City, Town, Location Other (Describe) PHYSICIAN PROVIDING CARE 9a. Name of Physician (Type or Print) 9b. Signature of Physician 10. Date of This Post-Abortion Care (Mo., Day, Yr.) MO 580-0353 (9-17) SCHS-8 (10-80)
20160727ComplicationRptPost-AbortionCareFillable0353Rev09-8-17.docx