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Instructions for Completing the Abortion Complication Report |
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Item |
Instructions |
| Facility or Physician Submitting Report |
Select the National Provider Identifier of the facility or physician submitting the report |
| Submitter Facility Type |
If the report is Submitted by a Facility, then Select the Facility Type |
| Facility Where the Abortion was Performed |
Select the National Provider Identifier of the facility where the Abortion was Performed |
| Facility Type of the Abortion Provider |
Select the Facility Type of the facility where the abortion was performed |
| Facility Where the Complication(s) was/were Diagnosed of treated |
Select the National Provider Identifier of the facility where complications were diagnosed or treated |
| Facility Type of the Diagnosing/Treatment Facility |
Select the Facility Type of the facility where complications were diagnosed or treated |
| Patient Year of Birth |
Select the Year of the Patient's Birth |
| Patient Marital Status |
Select the Marital Status of the Patient |
| Patient Race |
Select the Race of the Patient |
| Patient Ethnicity |
Select the Ethnicity of the Patient |
| Patient Residence State/Territory |
Select the U.S. State or Territory in which the Patient Resides |
| Patient Residence County/Parish |
Select the County/Parish withing the State of Residence where the Patient Resides |
| Previous Births Now Living |
Enter the number of live births that are still living |
| Previous Births Now Dead |
Enter the number of live births that have died |
| Previous Spontaneous Terminations |
Enter the number of spontaneous terminations (miscarriages) that have occurred |
| Previous Induced Terminations |
Enter the number of induced abortions that have occurred |
| Date of Last Menses |
Enter the date of the last normal menstrual period before the abortion |
| Date of Abortion |
Enter the date of the abortion |
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| Gestational Age of the Fetus |
Enter the gestational age of fetus at the time of the abortion |
| Date of Complication(s) |
Enter the date the patient’s complication was diagnosed or treated |
| Procedure Performed |
Select the Type of Procedure that terminated this pregnancy |
| Complication(s) |
Add as many Complications as were diagnosed or treated |
| Complication Explanation/Comment |
Enter any specifics of the complication as necessary |
Filing Instructions:
A physician who performs at an abortion facility that results in an abortion complication diagnosed or treated by the physician; or diagnoses or treats at an abortion facility an abortion complication that is a result of an abortion performed by another physician at the abortion facility must electronically submit no later than the third (3rd) business day after the date on which the abortion complication was diagnosed or treated.
A healthcare facility (hospital, abortion facility or a healthcare facility that provides emergency medical care) shall electronically submit on each abortion complication diagnosed or treated by the facility not later than the thirtieth (30th) day after the date on which the abortion complication was diagnosed or treated.
Form and electronic filing procedures can be found at www.healthy.arkansas.gov. |