Sexual Health Care Plans 2

Key Objectives

Provide patients with information about their procedure and collect information from the patient before their appointment to reduce clinic time and to support patient empowerment.

Outcome measures

Equip patients with the information they need before their appointment, also providing the tools they need to interact digitally rather than relying on face to face consultations.

Current Baselines

The patient arrives at the clinic. Information is explained to the patient and the nurse goes through a questionnaire/checklist with the patient, appointments aren’t being efficient and patients are having long waiting times.

Workflow

Coil fitting checklist care plan

Example care plan template code for Coil fitting checklist Care Plan HTML

.form-group {width: 100%; !important}

ul {list-style:inherit; margin-left: 15px;}

.cp_whiteBox_orange {background-color:#ffffff; padding:15px; margin-bottom:10px; margin-top:10px; -moz-border-radius: 10px; -webkit-border-radius: 10px; -khtml-border-radius: 10px; border-radius: 10px; border: 2px solid #FEC001;}

.cp_whiteBox_red {background-color:#ffffff; padding:15px; margin-bottom:10px; margin-top:10px; -moz-border-radius: 10px; -webkit-border-radius: 10px; -khtml-border-radius: 10px; border-radius: 10px; border: 2px solid red;}

.cp_colorBox {background-color: #ffffff; padding:15px; margin-bottom:10px; margin-top:10px; -moz-border-radius: 10px; -webkit-border-radius: 10px; -khtml-border-radius: 10px; border-radius: 10px;}

</style>

<h2>Coil fitting checklist - for intrauterine devices (IUD) and intrauterine systems (IUS)</h2>

<p>Please complete this checklist to ensure that we are able to fit your coil at your booked

appointment. This checklist will also provide you with some important information about

having a coil fitted.</p>

</div>

<p>Please watch the video below or read <a href="https://www.contraceptionchoices.org " target="_blank">the contraception

Choices website</a> before completing this form.</p>

</div>

<p>Please tick the boxes to confirm that you have understood and are ready to book your coil fitting appointment:</p>

<p>I have watched the video above on coils or I have read the <a href="https://www.contraceptionchoices.org " target="_blank">contraception

Choices website</a> or I already have an IUD/IUS and am familiar with this contraception method</p>

</div>

<p>I am using an effective method of contraception and haven't had any problems eg burst condom, missed pills, IUD overdue for change.</p>

</div>

<p>I have not had unprotected sex (or used the withdrawal method) since my last period.</p>

</div>

<p>I understand that it is not safe to insert an IUD/IUS if I might be pregnant.</p>

</div>

<p>I will make sure that I have eaten on the day of the appointment. (You may also wish to take an over-the-counter

painkiller 30 minutes before your appointment.)</p>

</div>

<p>I understand that an IUD/IUS is more than 99 per cent effective (less than 1 in 100 chance of pregnancy).</p>

</div>

<p>I understand that there is a small risk (1 in 1,000) that the IUD/IUS might go through (perforate)

my womb or cervix when it is put in. If this does happen, the IUD/IUS may have to be removed surgically.</p>

</div>

<p>I understand that there is a 1 in 20 chance of the device falling out.</p>

</div>

<p>I understand that there is a small risk of infection (1 in 100) in the first 20 days following insertion of a device.</p>

</div>

<p>I know that a copper IUD will make my periods slightly heavier, longer and more painful.</p>

</div>

<p>I know that an IUS will make my periods much lighter but causes erratic bleeding and spotting in the first few months of use.</p>

</div>

<p>I do not believe I am at risk of sexually transmitted infections (STIs) or I have been tested negative recently for

Chlamydia / Gonorrhoea. Risk factors for STI are having a new partner in the last 3 months or more than one partner

in the last year - we recommend you have a negative test before the procedure. Order yours at

<a href="https://www.friskywales.org " target="_blank">Frisky Wales</a></p>

</div>

Sub-dermal implant insertion checklist care plan

Key Objectives

Provide patients with information about their procedure and collect information from the patient before their appointment to reduce clinic time and to support patient empowerment.

Outcome measures

Equip patients with the information they need before their appointment, also providing the tools they need to interact digitally rather than relying on face to face consultations.

Current Baselines

The patient arrives at the clinic. Information is explained to the patient and the nurse goes through a questionnaire/checklist with the patient, appointments aren’t being efficient and patients are having long waiting times.

Example care plan template code for Sub-dermal implant insertion Care Plan HTML

.form-group {width: 100%; !important}

ul {list-style:inherit; margin-left: 15px;}

.cp_whiteBox_orange {background-color:#ffffff; padding:15px; margin-bottom:10px; margin-top:10px; -moz-border-radius: 10px; -webkit-border-radius: 10px; -khtml-border-radius: 10px; border-radius: 10px; border: 2px solid #FEC001;}

.cp_whiteBox_red {background-color:#ffffff; padding:15px; margin-bottom:10px; margin-top:10px; -moz-border-radius: 10px; -webkit-border-radius: 10px; -khtml-border-radius: 10px; border-radius: 10px; border: 2px solid red;}

.cp_colorBox {background-color: #ffffff; padding:15px; margin-bottom:10px; margin-top:10px; -moz-border-radius: 10px; -webkit-border-radius: 10px; -khtml-border-radius: 10px; border-radius: 10px;}

</style>

<h2>Sub-dermal implant insertion checklist</h2>

<p>Please complete this checklist to ensure that we are able to fit your implant at your booked

appointment. This checklist will also provide you with some important information about

having an implant inserted.</p>

</div>

<p>Please watch the video below or read <a href="https://www.contraceptionchoices.org " target="_blank">the contraception

Choices website</a> before completing this form.</p>

<p>(courtesy of Worcestershire Health and Care NHS Trust)</p>

</div>

<p>Please tick the boxes to confirm that you have understood and are ready to book your implant insertion appointment:</p>

<p>I have watched the video above on implants or I have read the <a href="https://www.contraceptionchoices.org " target="_blank">contraception

Choices website</a> or I already have an implant and am familiar with this contraception method</p>

</div>

<p>I am using an effective method of contraception and haven't had any problems eg burst condom, missed pills, IUD/Coil or Implant overdue for change</p>

</div>

<p>I have not had unprotected sex (or used the withdrawal method) since my last period.</p>

</div>

<p>I understand that an implant is more than 99 per cent effective (less than 1 in 1000 chance of pregnancy).</p>

</div>

<p>I understand that the Implant may alter my bleeding pattern, and that I may experience no bleeding,

or have irregular bleeding especially in the first few months.</p>

</div>

<p>I understand that medications such as some of those used to treat epilepsy, HIV and TB, and the

complementary medicine St John's Wort, may make the Implant less effective</p>

</div>

<p>I understand that if a new Implant is inserted outside of day 1-5 of the menstrual cycle, it is not

effective for 7 days and I should use another method of contraception, such as condoms.</p>

</div>

<p>If there is a risk of pregnancy at the time my implant is fitted I should do a pregnancy

test at 4 weeks after the insertion</p>

</div>

<p>I do not believe I am at risk of sexually transmitted infections (STIs) or I have been tested

negative recently for Chlamydia / Gonorrhoea. Risk factors for STI are having a new partner in

the last 3 months or more than one partner in the last year. Order a free test at

<a href="https://www.friskywales.org " target="_blank">Frisky Wales</a></p>

</div>

Contraceptive Pill Checklist care plan

Key Objectives

Provide patients with information about their procedure and collect information from the patient before their appointment to reduce clinic time and to support patient empowerment.

Outcome measures

Equip patients with the information they need before their appointment, also providing the tools they need to interact digitally rather than relying on face to face consultations.

Current Baselines

The patient arrives at the clinic. Information is explained to the patient and the nurse goes through a questionnaire/checklist with the patient, appointments aren’t being efficient and patients are having long waiting times.

Workflow

Admin: calls patient offering appointment and PKB
Admin: creates an appointment and adds care plan into PKB
PKB: notifies patient about appointment and care plan are in their record
Patient: fills in informed questionnaire care plan before the appointment
Patient: attends appointment for contraceptive pill advice and prescription
Professional: reviews answers in the care plan
Professional: prescribes the contraceptive pill
Professional: team-based messaging available to the patient for follow up instructions and questions

Evaluation

Reducing phone calls and contacts
Patient reduce coming back in for more contraception
The ability for patients to contact the team if they have any issues after starting the contraceptive pill
Women able to track symptoms in relation to the contraceptive pill
Record weight
Record BP when they get it checked at the GP
Library of different contraception options

Example care plan template code for Contraceptive Pill Checklist Care Plan HTML

a {word-wrap: break-word;}

.form-group {width: 100%; !important}

.cp_label {font-size: 18px;font-weight: 900;}

.cp_whiteBox {background-color:#ffffff; padding:15px; margin-bottom:10px; margin-top:10px; -moz-border-radius: 10px; -webkit-border-radius: 10px; -khtml-border-radius: 10px; border-radius: 10px;}

</style>

<p>Please complete these questions before your appointment.</p>

<p>To complete this form, please click the 'Edit plan' button in the top right of the page.</p>

<p>When you have answered all the questions, please click 'Save' in the bottom right of the page.</p>

</div>

<label class="cp_label" style="margin-top: 20px;" for="cp_q1">1. Are you currently using any kind of hormonal contraception?</label>

</div>

</div>

<label class="cp_label" for="cp_q1a">What is your current contraceptive? </label><input type="text" name="cp_q1a" id="cp_q1a"></input>

<label class="cp_label" for="cp_q1b">Would you like to change to another contraceptive? Please say why:</label><textarea name="cp_q1b" id="cp_q1b" style="width: 90%" rows="3"></textarea>

</div>

<label class="cp_label" style="margin-top: 20px;" for="cp_q1b">Have you used hormonal contraceptives in the past? Please specify any you have used: </label><input type="text" name="cp_q1bYesText" id="cp_q1bYesText"></input>

</div>

<label class="cp_label" style="margin-top: 20px;" for="cp_q2">2. Do you know the pill you would like to order?</label>

<input class="form-check-input" type="radio" name="cp_q2" id="cp_q2Combined" value="Combined"> Combined pill</input>

</div>

<input class="form-check-input" type="radio" name="cp_q2" id="cp_q2POP" value="POP"> Progestogen only pill</input>

</div>

</div>

<label class="cp_label" style="margin-top: 20px;" for="cp_q3">3. Have you had your blood pressure measured in the last 12 months?</label>

<input class="form-check-input" type="radio" name="cp_q3" id="cp_q3Yes" value="Yes"> Yes (if known, please enter reading and date at the top of this form)</input>

</div>

</div>

<label class="cp_label" style="margin-top: 20px;" for="cp_q4">4. Are you allergic to any medications or substances?</label>

</div>

</div>

<h3>If yes, please specify below:</h3>

<input class="form-check-input form-control" type="checkbox" name="cp_q4a" id="cp_q4a" value="penicillin"> Penicillin</input>

</div>

<input class="form-check-input form-control" type="checkbox" name="cp_q4b" id="cp_q4b" value="peanutSoya"> Peanuts or soya</input>

</div>

<input class="form-check-input form-control" type="checkbox" name="cp_q4c" id="cp_q4c" value="lactose"> Lactose</input>

</div>

<label class="cp_label" for="cp_q4aotherMeds"> Other medications: </label><input type="text" name="cp_q4aotherMeds" id="cp_q4aotherMeds"></input>

<label class="cp_label" for="cp_q4aotherSubs"> Other substances: </label><input type="text" name="cp_q4aotherSubs" id="cp_q4aotherSubs"></input>

</div>

<label class="cp_label" style="margin-top: 20px;" for="cp_q5">5. Do you smoke?</label>

</div>

</div>

<label class="cp_label" style="margin-top: 20px;">6. Are you pregnant or have you given birth in the last 6 weeks?</label>

<input class="form-check-input" type="radio" name="cp_q6" id="cp_q6a" value="pregnant"> I am pregnant or there is a chance I could be</input>

</div>

<input class="form-check-input" type="radio" name="cp_q6" id="cp_q6b" value="less than 3 weeks"> I gave birth in the last 3 weeks</input>

</div>

<input class="form-check-input" type="radio" name="cp_q6" id="cp_q6c" value="3-6weeks"> I gave birth in the last 3-6 weeks</input>

</div>

<input class="form-check-input" type="radio" name="cp_q6" id="cp_q6d" value="NoneOfAbove"> None of the above</input>

</div>

<h3>If you have given birth in the last 3-6 weeks:</h3>

<label class="cp_label" style="margin-top: 20px;" for="cp_q7a">Are you breastfeeding?</label>

</div>

</div>

<input class="form-check-input form-control" type="checkbox" name="cp_q7b" id="cp_q7b" value="transfusion"> Blood transfusion or significant blood loss</input>

</div>

<input class="form-check-input form-control" type="checkbox" name="cp_q7c" id="cp_q7c" value="Csection"> Caesarian section</input>

</div>

<input class="form-check-input form-control" type="checkbox" name="cp_q7d" id="cp_q7d" value="preeclampsia"> Pre-eclampsia during or after pregnancy</input>

</div>

<input class="form-check-input form-control" type="checkbox" name="cp_q7e" id="cp_q7e" value="None"> None of the above</input>

</div>

<label class="cp_label" style="margin-top: 20px;" for="cp_q8">7. Have you been diagnosed with high blood pressure?</label>

</div>

</div>

<label class="cp_label" style="margin-top: 20px;">Was it related to:</label>

<input class="form-check-input form-control" type="checkbox" name="cp_q8b" id="cp_q8b" value="pregnancy"> Pregnancy</input>

</div>

<input class="form-check-input form-control" type="checkbox" name="cp_q8c" id="cp_q8c" value="whitecoat"> White coat syndrome</input>

</div>

<input class="form-check-input form-control" type="checkbox" name="cp_q8d" id="cp_q8d" value="other"> Other</input>

</div>

<label class="cp_label" style="margin-top: 20px;" for="cp_q9a">8. Have you ever had a heart attack or stroke?</label>

</div>

</div>

<label class="cp_label" for="cp_q9b">Please give details of what happened, when, and the treatment you had: </label><textarea name="cp_q9b" id="cp_q9b" style="width: 90%" rows="3"></textarea>

</div>

<label class="cp_label" style="margin-top: 20px;" for="cp_q10">9. Have you had a blood clot before?</label>

</div>

</div>

<label class="cp_label" for="cp_q10b">Please provide details: </label><textarea name="cp_q10b" id="cp_q10b" style="width: 90%" rows="3"></textarea>

</div>

<label class="cp_label" style="margin-top: 20px;" for="cp_q11">10. Has someone in your close family had a blood clot?</label>

</div>

</div>

<label class="cp_label" for="cp_q11b">What relation were they to you? </label><input type="text" name="cp_q11b" id="cp_q11b"></input>

<input class="form-check-input" type="radio" name="cp_q11c" id="cp_q11cGT44" value="greater than 44"> 45 years old or over</input>

</div>

<input class="form-check-input" type="radio" name="cp_q11c" id="cp_q11cLT45" value="less than 45"> Less than 45 years old</input>

</div>

<label class="cp_label" style="margin-top: 20px;" for="cp_q12">11. Have you had major surgery in the last 3 weeks?</label>

</div>

</div>

<label class="cp_label" for="cp_q12b">Please provide details: </label><textarea name="cp_q12b" id="cp_q12b" style="width: 90%" rows="3"></textarea>

</div>

<label class="cp_label" style="margin-top: 20px;" for="cp_q13">12. Do you have diabetes?</label>

</div>

</div>

<label class="cp_label" for="cp_q13b">Please provide details: </label><textarea name="cp_q13b" id="cp_q13b" style="width: 90%" rows="3"></textarea>

</div>

<label class="cp_label" style="margin-top: 20px;" for="cp_q14">13. Do you have any conditions affecting your liver or kidneys?</label>

</div>

</div>

<label class="cp_label" for="cp_q14b">Please provide details: </label><textarea name="cp_q14b" id="cp_q14b" style="width: 90%" rows="3"></textarea>

</div>

<label class="cp_label" style="margin-top: 20px;">14. Have you ever had any of the following cancers? (select all that apply)</label>

<input class="form-check-input form-control" type="checkbox" name="cp_q15b" id="cp_q15b" value="Breast cancer"> Breast cancer</input>

</div>

<input class="form-check-input form-control" type="checkbox" name="cp_q15c" id="cp_q15c" value="Cervical cancer"> Cervical cancer</input>

</div>

<input class="form-check-input form-control" type="checkbox" name="cp_q15d" id="cp_q15d" value="Liver cancer"> Liver cancer</input>

</div>

<input class="form-check-input form-control" type="checkbox" name="cp_q15e" id="cp_q15e" value="Other cancers"> Other cancers</input>

</div>

<input class="form-check-input form-control" type="checkbox" name="cp_q15f" id="cp_q15f" value="Never had cancers"> Never had cancers</input>

</div>

<label class="cp_label" style="margin-top: 20px;" for="cp_q16">15. Do you ever have unexpected or unusual vaginal bleeding?</label>

</div>

</div>

<label class="cp_label" for="cp_q16b">How long have you had it? When did it happen last? </label><textarea name="cp_q16b" id="cp_q16b" style="width: 90%" rows="3"></textarea>

<label class="cp_label" style="margin-top: 20px;">Select all that apply:</label>

<input class="form-check-input form-control" type="checkbox" name="cp_q16c" id="cp_q16c" value="PCB"> Bleeding during or after sexual intercourse</input>

</div>

<input class="form-check-input form-control" type="checkbox" name="cp_q16d" id="cp_q16d" value="Heavy bleeding"> Heavy bleeding</input>

</div>

<input class="form-check-input form-control" type="checkbox" name="cp_q16e" id="cp_q16e" value="Very painful bleeding"> Very painful bleeding</input>

</div>

<input class="form-check-input form-control" type="checkbox" name="cp_q16f" id="cp_q16f" value="None of above"> None of the above</input>

</div>

<label class="cp_label" style="margin-top: 20px;" for="cp_q17">16. Have you had a STI test in the last 12 months or since your last new sexual partner?</label>

</div>

</div>

<label class="cp_label" for="cp_q17b">What were the results? </label><input type="text" name="cp_q17b" id="cp_q17b"></input>

</div>

<p>Please consider ordering a full STI screen through <a href="http://www.friskywales.org " target="_blank">http://www.friskywales.org </a></p>

</div>

<h3>17. If you are 25 years or older:</h3>

<label class="cp_label" for="cp_q18a">When was your last cervical smear? </label><input type="text" name="cp_q18a" id="cp_q18a"></input>

<label class="cp_label" for="cp_q18b">What was the smear result? </label><input type="text" name="cp_q18b" id="cp_q18b"></input>

</div>

<label class="cp_label" style="margin-top: 20px;" for="cp_q20">18. Do you have any other medical conditions?</label>

</div>

</div>

<label class="cp_label" for="cp_q20b">Please provide details: </label><input type="text" name="cp_q20b" id="cp_q20b"></input>

</div>

<label class="cp_label" style="margin-top: 20px;" for="cp_q21">19. Are you taking any medications currently or have recently finished a course of medication? (including over the counter medications)</label>

</div>

</div>

<label class="cp_label" for="cp_q21b">Please provide medication name, dose and what it was used for: </label><textarea name="cp_q21b" id="cp_q21b" style="width: 90%" rows="3"></textarea>

</div>