The code block below illustrates how one might use # and // as comments in your logic and calculations.

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Required format:

Ryan LARC Survey (L&D or Mother-Baby)

INSTRUCTIONS: How to Access Free LARC for your Postpartum Patient

Be an Ob/Gyn resident on L&D or Mother/Baby.

Make sure your patient is MEDICALLY and FINANCIALLY eligible for a Free Ryan LARC.

Immediately postpartum
Self-reported (annual household income that < 300% of the current FPL
Uninsured or underinsured (her insurance won’t cover LARC)

Make sure the program administrator is here to dispense your LARC.

Plan ahead! Call to make sure Becca is here to dispense your LARC, and that the LARC device requested is available.
Becca Medina: Extension 2-3392

Complete the Data Collection Survey with your patient.

Becca will receive an email confirming you completed the survey, and will walk over the LARC.

What happens if my first insertion is unsuccessful?

Not a problem. You may request another.
BUT! You must complete another survey.
Answer yes when survey asks whether you’re requesting a replacement for a contaminated device.

Date of Service

* must provide value

M-D-Y

Patient's Full Name (Last, First)

* must provide value

Patient's Date of Birth (test)

* must provide value

M-D-Y

Patient's Medical Record Number (MRN)

* must provide value

Clinical Training Site

* must provide value

UNMH L&D

UNMH Mother / Baby Unit

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Is this a request to replace a contaminated device?

A contaminated device is defined here as any device that had to be thrown away BEFORE the patient leaves the office; for example, failed insertion.

* must provide value

Yes

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Name of Learner

* must provide value

Training Level of Learner

* must provide value

Nursing Student/Trainee (RN, PA, APC, CNM)

Medical Student

Resident

Current Family Planning Fellow* (only list fellow here if under direct supervision of an attending)

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Name of Attending Physician

* must provide value

Timing of LARC Placement

* must provide value

Immediately Post-Surgical Abortion

Immediately Postpartum (postplacental or delayed inpatient)

Immediately Post-Spontaneous Abortion

Medical Abortion follow-up visit

≤10 weeks Post-Abortion

≤10 weeks Postpartum

≤10 weeks Post-Spontaneous Abortion

Medically or socially complex patient (description required)

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Resource: Medically Complex Patient Examples

Please see the attached document for examples of medically complex patients and populations.

**NOTE - Hold down the control button (Ctrl) on keyboard while clicking on the link***

Attachment:Medical Complexities.JPG

Resource: Socially Complex Patient Examples

Please see the attached document for examples of socially complex patients and populations

**NOTE - Hold down the control button (Ctrl) on keyboard while clicking on the link***

Attachment:Social Complexities.JPG

If Medically or Socially Complex, Please Specify:

LARC Device Requested

* must provide value

Liletta

Paragard

Nexplanon

Mirena

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Race/Ethnicity
(Read All Choices To The Patient)

* must provide value

White/Caucasian: Non-Hipanic

White/Caucasian: Hispanic

Black/African-American: Non-Hispanic

Back/African-American: Hispanic

Hispanic/Latino: Spanish Origin

Asian

Native Hawaiian/Pacific Islander

American Indian/Native Alaskan

Multi-Racial

Other (description mandatory)

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If Other Race/Ethnicity, Please Specify:

Education Level
(Read All Choices To The Patient)

* must provide value

Some high school

High school/GED

Associate's degree

Bachelor's degree

Graduate degree

Other (description mandatory)

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If "Other" Education Level, Please Specify

Relationship Status
(Read All Choices To The Patient)

* must provide value

Single

Partnered (not married, not living together)

Cohabiting (not married, living together)

Married

Other (description mandatory)

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If "Other" Relationship Status, Please Specify:

Employment Status

* must provide value

Unemployed

Working part-time

Working full-time

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OB History:
(Reproductive status at the time of LARC insertion. Include today's outcome if post-placental or post-abortion)

Gravida
(Total number of pregnancies)

* must provide value

Para
(Number of Living Children)

* must provide value

Primary Birth Control Method
(Method Used Prior to the Most Recent Pregnancy)

* must provide value

None

Natural Family Planning

Withdrawal

Barrier Method

OCP (oral contraceptive pills)

Shot

Patch

Ring

IUD/Implant

Other (description required)

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If "Other" Birth Control Method, Please Specify:

FINANCIAL ELIGIBILITY QUESTIONS

Number Of People In Household
(Including Patient)

* must provide value

Monthly Income For Household
(Patient May Estimate. No Documentation Required)

* must provide value

Resource: 2016 Federal Poverty Level Guidelines

Please use attached chart to determine whether patient's household income is less than 300% of the current FPL, based on the size of her household.

**NOTE - Hold down the control button (Ctrl) on keyboard while clicking on the link***

Attachment:FPL image for RedCap survey.JPG

Is patient's household income under 300% of the FPL, based on her household size?

* must provide value

Yes

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Insurance Ineligibility
(Why Can't Patient Use Insurance?)

* must provide value

Patient has no insurance for LARC / Patient is not eligible for Medicaid

Insurance does not cover LARC because of timing of placement

Burdensome copay because patient is out of network / We do not accept patient's insurance

Patient lacks insurance preapproval/authorization for insertion TODAY

Other (description required)

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If "Other" Financial Eligibilty, Please Specify:

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.