PRE-OP DIAGNOSIS: desired long-term, reversible contraception
POST-OP DIAGNOSIS: Same
PROCEDURE: Nexplanon ® placement
Performing Physician: _
Supervising Physician (if applicable): _
ICON : _ Negative
Site (check): [_] Right Arm [_] Left Arm Serial # _
Sterile Preparation: [_] Betadine [_] Chloraprep Expiration Date [_]
Insertion site was selected 8 – 10 cm from medial epicondyle and marked along with guiding site using sterile marker
Procedure area was prepped and draped in a sterile fashion. _ mL of 1% lidocaine _ withORwithout epinephrine used for subcutaneous anesthesia. Anesthesia confirmed.
Nexplanon ® trocar was inserted subcutaneously and then Nexplanon ® capsule delivered subcutaneously
Trocar was removed from the insertion site.
Nexplanon ® capsule was palpated by provider and patient to assure satisfactory placement.
Estimated blood loss of _ mL
Dressings applied: _ Adhesive Dressing _ Gauze/Tape _ Biocclusive
Followup: The patient tolerated the procedure well without complications. Standard post-procedure care is explained and return precautions are given.