IUD Insertion/Removal Procedure Note

Date/Time of Procedure: [Date and time]

Location: [Clinic/procedure room]

Primary Operator: [Name, credentials]

Chaperone: [Name and role / declined / not available—reason]

Interpreter: [Language and mode: in-person/phone/video] (Include only if interpreter used; otherwise omit entirely.)

Procedure

[IUD Insertion / IUD Removal / IUD Removal and Reinsertion / Attempted IUD Insertion—Aborted]

[One-line outcome summary capturing: device type, uterine sounding depth in cm, final string length in cm, patient tolerance, and complication status. For aborted procedures, state reason for abort and follow-up plan.]

Indication

[Clinical indication: contraception initiation, device expiration/replacement, bleeding management, patient desire for pregnancy or discontinuation, side effects, suspected malposition/expulsion, or other stated goal. Document patient's stated reason and clinician assessment.]

Pregnancy Exclusion

(Include for Insertion, Exchange, or Attempted Insertion; omit for Removal-only.)

[Method used to exclude pregnancy: criteria-based exclusion with specific criterion met, UPT result with date, and/or timing relative to recent delivery or abortion. Include LMP and cycle status if relevant. Note any contraindications reviewed. Example: "Pregnancy reasonably excluded by [criterion]. UPT [result] on [date]." If pregnancy cannot be reasonably excluded, document rationale for proceeding or deferring.]

STI Screening

(Include only when screening was performed or is clinically relevant; otherwise omit.)

[Cervicitis/PID symptoms: present / absent. GC/CT screening: up to date / obtained today / declined. If obtained today, note specimen type and site.]

Counseling and Consent

[Narrative summary: device options discussed and patient's choice, expected bleeding and cramping changes, lack of STI protection with condom counseling as appropriate, risks reviewed (pain, bleeding, vasovagal reaction, infection, expulsion, perforation, pregnancy/ectopic risk), logistics (duration of effectiveness, when to return, what to do if strings not felt). Pain management options offered (NSAIDs, topical or injected local anesthetic, paracervical block) and patient's choice. Consent attestation: risks/benefits/alternatives discussed, questions answered, patient agreed to proceed. Note if written consent obtained per facility policy.]

Time-Out

[Safety verification: correct patient confirmed with two identifiers, correct procedure confirmed, allergies reviewed. For insertion/exchange: correct device available, pregnancy exclusion confirmed.]

Examination and Preparation

(Include for Insertion, Exchange, or Attempted Insertion; omit for Removal-only.)

• Bimanual exam: [Uterine position, size, tenderness]
• Speculum exam: [Cervix appearance, discharge]
• Preparation: [Patient positioning, antiseptic agent, tenaculum application site]
• Anesthesia/analgesia: [Medication, dose, route, location / No anesthesia administered]

Procedure Details

(Document in chronological narrative. Include only elements applicable to procedure variant.)

• (For Removal or Exchange) [Strings visualized: yes/no. Removal method: gentle traction with ring forceps / alternate technique if strings not visible. Device removed intact: yes/no. If not intact, describe concern and next steps.]
• (For Insertion or Exchange) [Uterine sounding depth in cm and direction. Any resistance or stenosis and management. Cervical dilation if performed. Ultrasound guidance if used. Device placement per manufacturer instructions. Final string length in cm after trimming, or note if left long with rationale.]
• (For Aborted procedure) [Point at which difficulty occurred, patient tolerance, immediate management, and plan for reattempt, alternative contraception, or referral.]

Device Information

(Include applicable subsections based on procedure variant.)

Inserted Device (Insertion or Exchange only)

• Device Type: [Cu-IUD / LNG-IUD]
• Brand/Model: [Paragard / Mirena / Kyleena / Liletta / Skyla / other]
• Lot Number: [Lot number / not available—reason]
• Expiration Date: [MM/YYYY / not available—reason]
• UDI: [UDI if captured via barcode scan / not captured]

Removed Device (Removal or Exchange only)

• Prior Device Type/Brand: [Type and brand / unknown]
• Approximate Original Insertion Date: [Date / unknown]
• Condition on Removal: [Intact / not intact—describe]

Tolerance and Complications

[Patient tolerance: well / fair / poor. Pain rating: 0–10 scale if collected. Vasovagal symptoms and management if applicable. Complications: None / list specific complications (excess bleeding, suspected perforation, difficult insertion, cervical laceration, syncope, device malposition, failed insertion) with management. Post-procedure checks: hemostasis at tenaculum site, strings visualized, vital signs if rechecked.]

Aftercare and Follow-Up

• Expected symptoms: [Cramping, spotting; OTC pain management guidance provided]
• Backup contraception: [Cu-IUD: none needed / LNG-IUD: 7 days backup if placed more than 7 days after menstrual bleeding start or during amenorrhea; otherwise none needed] (Include for Insertion or Exchange only.)
• Warning signs reviewed: [Fever/chills, severe or worsening pelvic pain, heavy bleeding, foul discharge, suspected expulsion, positive pregnancy test]
• Follow-up plan: [No routine follow-up, return as needed / Scheduled in 4–6 weeks for string check—rationale: clinic protocol / difficult insertion / patient preference]
• STI results follow-up: [Plan for results review and notification] (Include only if screening obtained.)