Contraception Counseling Note (Shared Decision-Making)

Date/Time: [Encounter date and time]

Clinician: [Name, credentials]

Visit Type: Contraception counseling (shared decision-making)

Interpreter: [Interpreter language and modality] (Include only if used)

Chief Concern

[Reason for visit in 1–2 lines; may include brief patient quote]

Reproductive Goals and Preferences

[Pregnancy intention and time horizon; patient priorities and values regarding contraception such as bleeding changes, hormone exposure, efficacy, reversibility, privacy, maintenance frequency, or cost] (Use patient-centered language. Direct quotes appropriate when they clarify preferences. If patient declines counseling, document that explicitly.)

Safety Screening and Eligibility

Pregnancy status: [Basis for reasonably excluding pregnancy, or statement that pregnancy cannot be excluded] (Document specific CDC criterion: LMP and timing of intercourse, current method adherence, postpartum/postabortion status, or urine pregnancy test with result. Never document "not pregnant" without the basis. Prompt for clarification if missing.)

Medical eligibility screening: [Pertinent positives and negatives for conditions affecting method safety] (Include only conditions explicitly assessed: hypertension, migraine with/without aura, smoking/nicotine, VTE/PE history, stroke/TIA, breast cancer, liver disease, relevant drug interactions. Do not document as negative unless explicitly addressed.)

Blood pressure: [BP value and source] (Required if combined hormonal contraception is considered or selected. Credible external BP acceptable. Prompt for clarification if CHC planned and BP missing.)

Relevant history: [Menstrual pattern concerns, prior contraceptive methods and reasons for discontinuation, pertinent obstetric or gynecologic history affecting method choice] (Include only elements that were discussed.)

Counseling and Decision-Making

Options reviewed: [Method categories discussed: LARC, short-acting hormonal, barrier, fertility awareness, permanent, emergency contraception as relevant] (Note if patient declined discussion of any categories.)

Risks, benefits, and alternatives: [For methods seriously considered: effectiveness, common side effects and expected bleeding changes, rare serious risks, relevant noncontraceptive benefits, reversibility, STI protection limitations] (Focus on what aligns with patient's stated goals.)

Patient rationale: [How patient preferences and values informed the chosen method or decision to defer] (Use patient's terms; quotes helpful when clarifying reasoning.)

Informed consent: [Questions invited and answered; alternatives including no contraception discussed; patient understanding confirmed; choice was voluntary] (For IUD or implant, note that procedural consent and technical details are in a separate procedure note.)

Plan

Selected method: [Method name and formulation; dose/route/frequency if prescription; start date and initiation strategy; backup contraception requirements and duration; missed-dose guidance referenced]

If pregnancy uncertain: [Interim plan or barrier method; backup/abstinence instructions; timing for follow-up pregnancy test] (Include only if applicable.)

STI prevention: [Condom counseling; STI tests ordered or declined; PrEP discussion if relevant] (Include only if discussed.)

Follow-up: [Method-specific follow-up or statement that no routine follow-up required; return precautions; how to access urgent care]

Patient instructions: [Written materials or resources provided; confirmation of understanding]

(Omit elements not discussed or not applicable. Reflect the patient as the decision-maker throughout; avoid directive language. Pregnancy status basis and blood pressure when CHC is considered are required—prompt for clarification if missing.)