Family Planning Documentation

Family planning documentation is the record of each consultation: who attended, what was assessed, what was advised and provided, and what follow up was arranged. Good records protect the patient, support continuity of care, allow safe resupply and tracing of devices, and feed facility reporting and supply planning. This article describes what to record at each visit and how to keep records.

Scope. All family planning contacts: new and revisit clients, method provision, procedures (implant, IUD, sterilisation, vasectomy), emergency contraception, referrals, side effects and discontinuation, at facility and community level.

Purposes of the record.

• Safe, continuous care: others can find what was done and when the next action is due.

• Legal protection: proof of consent, counselling and the procedure performed.

• Traceability: product name, strength, batch and expiry for any product or device.

• Reporting and supply planning: counts of clients and methods used.

Who records. The provider who delivers the service records it at the time of the visit, signs and dates the entry. The facility in-charge reviews the quality of records.

Records and tools.

• A client card or file for each patient, with clinical evaluation, method and follow up.

• A follow up or revisit card kept by the patient with the method, dates and contact details.

• A daily family planning activity register recording new clients, revisits, method dispensed and method switches.

• A monthly summary form for reporting.

• Referral forms, procedure consent forms and adverse event forms.

• Postnatal and antenatal registers where a method is given at those visits.

Confidentiality. Keep records locked, restrict access, never discuss a patient's method with others without consent, and agree how to contact the patient (a phone call or message with no mention of contraception).

Data quality. Entries are complete, accurate and legible; totals are reconciled each month; supervisors review and correct errors.

Minimum content at each visit.

• Identification: name or code, age, address or contact (as the patient allows), parity and number of living children.

• Reason for visit: new client, revisit, switch, problem, removal, emergency contraception.

• Reproductive intention and preferences.

• History: last menses, breastfeeding, pregnancy exclusion basis, medical conditions and medicines, smoking, allergies, STI and HIV risk.

• Examination: blood pressure and weight where taken; pelvic and genital findings where done.

• Counselling given and method chosen, with the patient's reasons.

• Eligibility category, and the decision if it was category 3.

• Consent: verbal or written, and for sterilisation and vasectomy the signed form.

• Method provided: name, strength or dose, route, quantity supplied, batch number and expiry, date started, next due date, and backup advised.

• Follow up date, referral made, and instructions given.

• Provider's name and signature, and date.

Procedure records.

• Implant: type, number of rods, arm, site, batch number, date of insertion and planned removal date, any difficulty.

• IUD: type, batch number, uterine depth sounded, string length left, difficulty or pain, analgesia, date and review date.

• Sterilisation and vasectomy: technique, findings, anaesthesia, complications, consent and follow up, and later semen analysis results.

• Removal: reason, technique, whole device removed, new method.

Special entries.

• Side effects and complications, actions taken, and referral.

• Emergency contraception doses and ongoing methods.

• DMPA-SC self injection: training done, doses dispensed, dates.

• Discontinuation: reason and next method.

Documentation practice.

• Record at the time of the visit, in ink or the electronic system, with date and signature.

• Correct errors by a single line and a signed correction, not by erasing.

• Complete the daily register for every contact and the monthly summary before the reporting date.

• Retain records for the period set by the facility and national rules.

• Give the patient a card and explain what is recorded.

Supply link. Record the product, strength, quantity and batch of each commodity issued in the daily register so that consumption data can be reported and used to order stock.

Quality checks.

• Review a sample of records each month for completeness (consent, pregnancy exclusion, category, batch, follow up date).

• Compare daily register, client cards and stock issued, and resolve discrepancies.

• Audit records for implant and IUD insertions to ensure traceability of devices.

• Feed audit results back to providers and agree corrections.

Safety.

• Incomplete records lead to missed follow up, unsafe resupply and unreported adverse events.

• Missing consent forms are a serious safety and legal gap.

Privacy risks. Records stored in open areas, shared passwords and public disclosure of lists are breaches; report and correct them.

Escalation. Escalate missing or falsified records, loss of records, breach of confidentiality, consent not documented for permanent methods, and data that do not reconcile with stock, to the facility in-charge and supervisor.