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MTP Forms

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sujata sahu
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34 views

MTP Forms

Uploaded by

sujata sahu
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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SH/JNR/FF/DOC-70/R0

Serial Number Affix Patient’s Sticker bearing


as per Assigned Serial Number of
Admission Register the Patient

Responsibility CHECKLIST FOR MTP CASES Response Signature


Custodian of the Have you entered Patient’s name in the Admission Register?
MTP Admission
Register Have you assigned a serial number to the patient as per The
MTP Act?
Front Office Has a new UHID been created for the patient using the
assigned serial number in place of NAME?

Has the Admission been made on new UHID?


Have you pasted the Patient’s Sticker on the Checklist for
MTP Cases?
Have you attached the Checklist in the Patient File?
Have you Informed the Medical Head regarding a patient
being admitted for MTP?
Gynecologist Stated LMP of the Patient ____Wks.

Length of Pregnancy -_______Weeks based on the USG Report


dated performed at
(name of the Centre)

Have you got the Form C filled & signed by the patient?

Have you taken the Informed Procedure Consent?


Form 1 Filled & Signed by the Gynecologist (Pregnancy less
than 12 Weeks) performing the procedure
Form 1 Filled & Signed by Two Gynecologists (Pregnancy
between 12 to 20 Weeks)
Form E Filled & Signed by Two Gynecologists
(Pregnancy between 20 to 24 Weeks)
Head Medical Give Clearance after checking that the above points are in order
Administration
MD Give Clearance for cases between 17- 24 weeks after
checking that the above points are in order
Assigned Nurse Have you verified that the checklist above is complete before
(Ward) shifting the patient?
OT Manager /
Have you checked that the above checklist is complete before
LDR I/C / taking the patient in the OT?
Nurse I/C
Gynecologist Ensured that Signed Form C & Form (1 or E) are
placed in an envelope
Ensured that the following are written on the Envelope :

SECRET
Serial Number assigned to the Patient in the Admission
register
Name and address of the Gynecologist(s)
Date on which the pregnancy was terminated
Ensured that the Envelope is sealed & attached to the
Checklist in the case file of the patient
Assigned Nurse Confirmed that the identity of the patient is not revealed
(at the time of anywhere in the case sheet & the above Checklist is complete
discharge) Sending the Sealed Envelope & Checklist to the Custodian of
Sealed Envelopes & the Checklist to the Custodian of the
MTP Admission Register
Custodian of Have received the sealed envelope for the above mentioned
the Sealed patient
Envelopes
Custodian of Ensured that all the entries in the admission register are
the MTP completed
Admission Register
Head Medical
Administration I have checked the above case file

MRD to accept Case File only once the Check List is complete. This Checklist to be retained as a
part of the Case File
SH/JNR/FF/DOC-48/R7
SH/JNR/FF/DOC-23/R0

FORM I
RMP Opinion Form
(For gesta on age upto twenty weeks)

[See Regula on 3]
I _________________________________________________________________________________
(Name and qualifica ons of the Registered Medical Prac oner in block le ers)

__________________________________________________________________________________
(Full address of the Registered Medical Prac oner)

hereby cer fy that I am of opinion, formed in good faith, that it is necessary to terminate the
pregnancy of _______________________________________________________________________

(Full name of pregnant woman in block le ers)


resident of_________________________________________________________________________
(Full address of pregnant woman in block le ers)
for the reasons given below*.
I hereby give in ma on that I terminated the pregnancy of the woman referred to above who bears
the Serial No. ______________________ in the Admission Register of the hospital/approved place.

Place:

Date:

Signature of the Registered Medical Prac oner

*of the reasons specified items (a) to (e) write the one which is appropriate:
a. in order to save the life of the pregnant women,
b. in order to prevent grave injury to the physical and mental health of the pre gnant woman,
c. in view of the substan al risk that if the child was born it would suffer from such physical
or mental abnormali es as to be seriously handicapped,
d. as the pregnancy is alleged by pregnant woman to have been caused by rape,
e. as the pregnancy has occurred as a result of failure of any contracep ve device or methods
used by a woman or her partner for the purpose of limi ng the number of children or
preven ng pregnancy.

Note: Account may be taken of the pregnant woman’s actual or reasonably foreseeable environment
in determining whether the con nuance of her pregnancy would involve a grave injury to her physical
or mental health.

Place:

Date: Signature of the Registered Medical Prac oner


SH/JNR/FF/DOC-71/R0

FORM E

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