Contraceptive Implant Insertion/Removal Procedure Note

Procedure: [insertion / removal / exchange] of etonogestrel implant

Date/Time: [Procedure date and time]

Proceduralist: [Name, credentials]

Location: [Clinic/facility and room]

Laterality: [left arm / right arm]

Assistant/Chaperone: [Name and role] (Include only if present)

Indication and Clinical Context

• Indication: [Reason for procedure: contraceptive initiation / continuation / postpartum timing / expiration / side effects / desire for pregnancy / preference change / device concern]
• Arm selection: [Dominant hand: right/left] | [Rationale if insertion site is dominant arm]
• Pregnancy risk assessment: (Include for insertion only)
  • LMP: [Date or unknown]
  • Recent unprotected intercourse: [Timing or none]
  • Current/recent contraception: [Method and adherence]
  • Postpartum/breastfeeding status: [Details if applicable]
  • Pregnancy status determination: [Criteria met for "reasonably certain not pregnant" / pregnancy test result / pregnancy cannot be excluded with plan for backup method and follow-up testing]
  (Do not infer pregnancy status from incomplete information)
• Contraindication screening: [Performed, no contraindications identified] or [Pertinent positives noted]

Informed Consent

• Consent obtained: [written / verbal]; patient demonstrated capacity and consented voluntarily
• Alternatives discussed: [Other contraceptive methods, no procedure, delayed timing]
• Risks reviewed: pain, bruising, bleeding/hematoma, infection, scarring, failure/unintended pregnancy, irregular bleeding pattern changes, difficult removal, deep or non-palpable placement, broken device, rare migration, nerve/vascular injury
• Questions answered: [yes / none asked]; patient agreed to proceed

Pre-Procedure Verification

• Patient identity: confirmed with two identifiers
• Procedure and laterality: verified
• Time-out: [performed / not performed]
• Allergies reviewed: [No relevant allergies / allergies to anesthetic or antiseptic noted]
• Device check: packaging intact and not expired (Include for insertion only)

Insertion Details

(Include this section only if insertion was performed)

• Device: [Brand name] | Lot# [Lot number] | Exp [Expiration date] | Removal due: [Date communicated to patient]
• Site preparation: [Anatomical location on inner upper arm with landmarks] | Skin prep: [Agent] | Sterile technique maintained
• Anesthesia: [Agent, concentration, volume, infiltration location along insertion track]
• Technique: Applicator inspected with implant visible at needle tip | Subdermal insertion at appropriate angle | Deployment completed
• Confirmation: Provider palpated full rod length [yes / no] | Patient palpated and confirmed [yes / no]
• Dressing: Adhesive bandage applied | Pressure bandage applied with instructions to remove in [Duration]
• Non-palpable implant protocol: (Include only if implant NOT palpable after insertion)
  • Applicator checked: [Deployment confirmed / not confirmed]
  • Patient instructed NOT to rely on implant for contraception until location confirmed
  • Backup contraception advised: [Method and duration]
  • Imaging ordered: [Ultrasound / X-ray / other]
  • Follow-up plan: [Timeline and instructions]

Removal Details

(Include this section only if removal was performed)

• Pre-removal assessment: Implant palpable: [yes / no] | Distal and proximal ends marked | Laterality verified against prior records
• Localization imaging: [Not required—implant palpable / imaging performed with results] (Do not proceed with blind exploration if non-palpable)
• Anesthesia: [Agent, concentration, volume, location—placed to keep implant superficial]
• Technique: Skin prep: [Agent] | Sterile technique maintained | Incision: [Size and orientation] | Removal method: [Expression / dissection / forceps]
• Hemostasis: [Achieved spontaneously / method used]
• Closure: [Adhesive strips / sutures (type and number)]
• Dressing: [Type applied]
• Removal confirmation: Implant removed [intact / broken] | Length: [Measurement, expected 4 cm] (If broken or partial, document segment lengths and plan for remaining fragment)

Exchange Details

(Include this section only for exchange procedures; complete both Removal Details and Insertion Details sections above)

• Approach: Reinsertion via [same incision / new incision] in [same arm / contralateral arm]
• Rationale for contralateral arm: [Reason if applicable]
• Removal confirmed complete prior to reinsertion: [yes]
• Additional anesthesia for reinsertion: [yes—details / not required]
• New device: Lot# [Lot number] | Exp [Expiration date]

Post-Procedure

• Tolerance: [Tolerated well / symptoms: pain, vasovagal response, other]
• Complications: [None / specify: hematoma, paresthesia, difficult localization, broken implant, syncope, other]
• Estimated blood loss: [Volume] (Include only if notable bleeding occurred)
• Neurovascular assessment: Distal sensation [intact / diminished] | Motor function [intact / diminished] | Perfusion [intact / diminished] (Include if difficult procedure, deep placement, or patient reports numbness/tingling)
• Wound care instructions: Remove pressure bandage in [Duration] | Keep site clean and dry | Expect bruising
• Return precautions reviewed: fever, increasing redness/swelling/drainage, severe pain, persistent numbness, inability to palpate implant after swelling resolves, symptoms suggesting migration
• Contraceptive efficacy: [Effective immediately / effective after 7 days—backup contraception advised] (Document specific guidance based on cycle timing)
• STI counseling: Implant does not protect against sexually transmitted infections
• Follow-up: [Routine PRN / scheduled for: non-palpable implant, complex procedure, pregnancy test follow-up, other concern]
• Documentation: Implant identification card given: [yes / no] | Chart label affixed: [yes / no]

Signature: [Proceduralist name, credentials]   Date/Time: [Signature date and time]