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The Miscarriage Discharge Paper form serves an essential role in the sensitive context of early pregnancy loss. Designed for use by physicians in an office setting, this form provides vital documentation for women who have experienced a miscarriage. It begins by confirming the pregnancy status through a positive pregnancy test and, if applicable, the results of an ultrasound. The form outlines various scenarios, such as a negative pregnancy test indicating a miscarriage or the confirmation of a miscarriage with fetal products of conception. Importantly, it clarifies that the miscarriage was not the result of a purposeful termination of pregnancy. Additionally, it informs the mother about her rights regarding the registration of fetal death and the options available for handling fetal remains. This includes the possibility of arranging private funeral services or allowing the physician to manage the disposal of remains in compliance with state law. The form also requires the mother’s signature, ensuring that she is fully informed and consenting to the choices presented. By addressing these aspects, the Miscarriage Discharge Paper form provides a compassionate framework for navigating a profoundly difficult experience.
Document Data
| Fact Name | Description |
|---|---|
| Purpose | This form is designed for physicians to confirm early pregnancy loss and inform the patient about their rights regarding fetal death registration. |
| Patient Information | The form requires the woman’s name and the date of the positive pregnancy test, along with details about the pregnancy's status. |
| Options for Miscarriage | Patients can select from multiple options regarding the nature of the miscarriage, including whether a fetus was confirmed or if a miscarriage occurred without visual confirmation. |
| State-Specific Registration | In certain states, individuals have the option to register a fetal death. The governing laws vary by state and may include specific procedures for submission to local authorities. |
| Disposition of Remains | The form allows patients to indicate their preference for the disposal of fetal remains, which can be handled by the physician in accordance with state law. |
How to Write Miscarriage Discharge Paper
Filling out the Miscarriage Discharge Paper form is an important step in documenting the loss and understanding the options available afterward. After completing the form, you will have the necessary documentation to discuss next steps regarding fetal remains and any potential memorial services.
- Begin by writing the woman's name in the designated space for woman’s name.
- Fill in the date of the positive pregnancy test in the space provided for date.
- Indicate whether the pregnancy was confirmed by an ultrasound by selecting either was or was not.
- In the next section, fill in the date when the miscarriage occurred.
- Select the appropriate option that describes the miscarriage situation:
- Had a negative pregnancy test signifying a miscarriage, ectopic pregnancy, false pregnancy test, blighted ovum, etc. No fetus was ever confirmed or visualized.
- Had a miscarriage of fetal products of conception (placenta, bleeding, etc.) confirmed by dropping Beta HCG hormone test. The miscarriage was not, to the best of my knowledge, the result of the purposeful termination of a pregnancy.
- Had a miscarriage of a ___________week fetus/infant that was delivered with no sign of life. The miscarriage was not the result of the purposeful termination of a pregnancy.
- Print the physician's name in the space labeled Physician Printed Name.
- Have the physician sign in the Physician Signature section.
- Fill in the date in the Date section.
- Indicate the state where the fetal death occurred in the state of section.
- Decide if you want to register your fetal death. If yes, be prepared to submit the statement to the local Registrar of Vital Statistics.
- If applicable, have the father sign a notarized document to accompany the application.
- Choose whether you would like the physician to handle the disposal of the fetal remains. Mark Yes or No accordingly.
- Sign the form in the Signature of Mother section.
- Fill in the date in the Date section for the mother’s signature.
Miscarriage Discharge Paper Example
FORM FOR USE BY PHYSICIANS IN AN OFFICE SETTING
EARLY PREGNANCY LOSS
CONFIRMATION OF MISCARRIAGE AND NOTICE OF RIGHT TO FETAL DEATH
CERTIFICATE
This is to certify that _____________________ (woman’s name) had a positive pregnancy test
on ______ (date).
This (was/ was not) confirmed as an intrauterine pregnancy by an ultrasound.
On ______ (date) ___________ (woman’s name):
Select appropriate option:
•Had a negative pregnancy test signifying a miscarriage, ectopic pregnancy, false pregnancy test, blighted ovum, etc. No fetus was ever confirmed or visualized.
•Had a miscarriage of fetal products of conception (placenta, bleeding, etc) confirmed by dropping Beta HCG hormone test. The miscarriage was not, to the best of my knowledge, the result of the purposeful termination of a pregnancy.
•Had a miscarriage of a ___________week fetus/infant that was delivered with no sign of life. The miscarriage was not the result of the purposeful termination of a pregnancy.
Physician Printed Name: ____________________________
Physician Signature: ____________________________ Date: ____________
In the state of __________, you have the option to register your fetal death. If you want to
exercise this option, you must submit this written statement to the local Registrar of Vital Statistics in the district where the fetal death occurred. If the father submits the application, he must also include with this statement a signed and notarized document from you attesting that you voluntarily provided the father with a copy of this statement.
You can use the fetal death certificate to arrange private funeral services and burial. You may also choose to have the physician dispose of the fetal remains in accordance with _________
state law. There is no charge for this service of cremation without ashes. You will need to sign the disposition form designating your choice of disposition of the remains.
Would you like the physician to handle disposal of the fetal remains if fetal remains can be identified. Yes No
Signature of Mother: _______________________ Date: _________________________
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