Nexplanon Insertion Procedure Note

PRE-OP DIAGNOSIS: desired long-term, reversible contraception 
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.
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