Objective: Contraceptive counselling at the time of an abortion is crucial for preventing new unintended pregnancies especially in teenagers. What is discussed on this occasion should be recorded in the patient's file. In this study we examined what was documented in medical records (MRs) about previous contraceptive use and further plans as a reflection of what was discussed between the gynaecologist and the teenager.
Methods: Thirty-six MRs were consecutively selected in 2006. The study design was descriptive, retrospective and qualitative. Data were analysed using qualitative content analysis. The text areas were transcribed and analysed in several steps.
Results: Two themes were generated from the analysis: 'Contraceptive methods previously used' and 'Plan for future contraceptive use'. Information on previous contraceptive use was absent in ten MRs. In five MRs data about future contraceptive use were missing and eight teenagers had not started a contraceptive method at follow-up.
Conclusion: The MR often lacked information about contraception; this could be a reflection of insufficient contraceptive counselling at the abortion-visit. Both contraceptive counselling and documentation thereof must be improved to enhance contraceptive use in teenagers.
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