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Guidance note for completing HSA4 paper forms

Updated 20 December 2022

Applies to England and Wales

This guidance has been updated to reflect the additional information required to be provided in relation to the use of medicines at home for early medical abortion following the amendment to the abortion legislation. The additional information covers:

• situations where both or one of the medicines is taken at home
• situations where treatment is entirely in hospital or clinic
• whether any part of the patient pathway (consultation and treatment) was provided face to face (in person)
• an optional question on which organisation provided the termination

There will be a 3-month transition period (between 31 December 2022 and 31 March 2023) during which it will be optional for practitioners or providers to submit the additional information if systems allow for this. Practitioners or providers will be legally required to submit this additional data where the medicine prescription for EMA was prescribed on or after 1 April 2023.

Introduction

Registered medical practitioners must complete and send HSA4 forms to the Chief Medical Officer (CMO), in accordance with the Abortion Act 1967, within 14 days of the termination.

Contact details

For England, you must send completed paper forms to The Chief Medical Officer, 39 Victoria Street, London, SW1H 0EU.

For Wales, you must send completed paper forms to The Chief Medical Officer, National Assembly for Wales, Cathays Park, Cardiff, CF10 3NQ.

If you require further information on completing HSA4 forms, you should telephone 020 7972 5541 or email abortion.statistics@dhsc.gov.uk.

General notes

A sample paper HSA4 form and ordering information are available online.

Paper forms must be ordered and not printed or copied. This is because forms are filed using the unique barcode at the bottom of each page.

The paper HSA4 form has been designed to be electronically scanned and for certain information to be read across into a database. It’s therefore important that all numbering and writing is kept within the boxes, and boxes that do not need to be completed are kept blank.

Patient stickers placed in the address box on page 2 slow down the processing system, especially those with faint type and patient barcodes. In addition, the amount of information included on these stickers (for example, the patient’s name, full address, GP name and GP address) is not required by the Department of Health and Social Care (DHSC) and inclusion of this information increases the risk to patient confidentiality. If sticky labels must be used, you should ensure that the ink is clear and dark and that the label fits within the box provided. Patient stickers with barcodes should not be used as these interfere with the electronic filing system used for the forms. If rubber stamps are used, you should ensure that the stamps are legible.

Currently, around 10% of paper HSA4 forms received are returned to registered medical practitioners because of missing, incomplete or invalid data. The main errors that occur are missing doctors’ names on page 1, and missing gestation and missing ground information, both on page 4. Incomplete forms will be returned to either the practitioner terminating the pregnancy or to the place of termination. If an amended form is not returned within 6 weeks, reminders will be sent until the information is received. Incomplete forms generate additional work for those completing the forms and for those who process them on behalf of the CMO. Therefore, you must ensure that all information is entered accurately.

Using the online facility

We encourage registered medical practitioners and administrators, if possible, to complete HSA4 forms electronically – using the online Abortion Notification System (ANS). This enables more efficient processing of the forms for those who work on behalf of the CMO, reduces risk of inadvertent disclosure of patient details and is less likely to result in follow-up queries from the department’s Abortion Statistics team, as the data is validated during the submission process. Detailed guidance on completing the electronic HSA4 form is available online.

If you still wish to proceed with submitting paper HSA4 forms, the following guidance explains how.

Section 1: practitioner terminating the pregnancy

You must provide a full name, address and General Medical Council (GMC) registration number, signature and date.

The address stated does not have to be the one shown on the GMC’s annual registration certificate. However, if the form is incomplete and the place of termination is missing, the form will be returned to the address held by the GMC.

You must also complete the declaration, as appropriate. In the case of medical terminations, the form must be signed even if the practitioner has been unable to confirm that the pregnancy has been terminated (see section 4 of this guidance, below).

Forms will be returned if the practitioner’s name, address, GMC number or signature are missing or if the GMC number cannot be found on the GMC register.

For medical abortions, when more than one doctor may be involved in the termination, the terminating practitioner is the doctor taking responsibility for the abortion. Usually, this will be the practitioner prescribing the mifepristone.

Section 2: certification

You must provide the full name and address of both registered medical practitioners who joined in giving the HSA1, unless one was the practitioner who terminated the pregnancy, and then complete the information on certification in the yes/no boxes underneath.

Forms will be returned if no information is given, if a hospital stamp is used but no doctor’s name is given or if the same doctor is given twice as shown in section 1.

Section 3: patient’s details

Patient’s reference

You should state the patient’s hospital or clinic number or NHS number. Only provide the patient’s full name if the patient’s hospital or clinic number or NHS number is not available.

Date of birth

In all cases, you must state the patient’s date of birth. Written confirmation of date of birth is required for patients aged under 13 and must be given on page 7.

Postcode

For UK residents, you should state the patient’s full postcode. If the full postcode is not available, state the patient’s complete address. Forms will be returned if a valid patient postcode or full address is not provided.

For Republic of Ireland residents, you should write ‘Irish Republic’ and select the relevant county. Forms will be returned if no Irish county is given.

For other, non-UK residents, you should provide the country of residence. If the country of residence is not known, you should state the full postcode or address for the patient’s temporary stay in England or Wales. Forms will be returned if a country of residence is not given or the full postcode or address is not given for the patient’s temporary stay in England or Wales.

Ethnicity

You must complete the relevant box for the patient’s self-reported ethnicity. Such information is also vital to addressing health inequalities and improvements in public health and commissioning functions.

If the patient’s self-reported ethnicity is not known, you should select ‘Not known’.

Marital status

You must complete the patient’s marital status, if known. If the patient is ‘single’ but in a long-term relationship and/or living with their partner, you should tick ‘single (with partner)’. If the patient is single and the partner status is not known, you should select ‘single (partner status not known)’.

If the patient’s marital status is not known, you should select ‘not known’.

Parity

For parity, you must enter the numbers of any previous pregnancies (resulting in live births and stillbirths over 24 weeks), spontaneous miscarriages and ectopic pregnancies, and legal terminations in the boxes as appropriate. The first pair of boxes is for live births and still births over 24 weeks, the second pair is for spontaneous miscarriages/ectopic pregnancies and the final is for legal terminations. If, for example, a woman has had 1 live birth, 1 stillbirth and 1 previous miscarriage, you should enter as ‘02 + 01 + 00’.

Forms will be returned for clarification if parity is 5 or over and no confirmation is given on the form. Additionally, forms where parity is greater than 2 and age is less than 16 will be returned for confirmation of both date of birth and parity.

Section 4: treatment details

Unless you are completing the form for an early medical abortion where all medicines were administered at the patient’s usual place of residence (home), you must provide the name and address of the place of termination in the box and then tick the relevant box to confirm whether the abortion was funded by the NHS or funded privately.

You should leave the hospital/clinic code box empty – DHSC staff will complete this.

If stamps are used, you should ensure that the information is clear.

The place of termination must be an NHS hospital or a DHSC-registered place of termination.

If both medicines are to be administered at the patient’s usual place of residence, the place of termination should be left blank.

Feticide

If feticide is used, you must complete the date and method at 4b before then going on to complete 4c or 4d to record the method used to evacuate the uterus. Feticide is recommended for abortions at 22 weeks and beyond. Forms without feticide information provided will be returned for confirmation that none was used.

If feticide was offered and the patient refused, you should record this on page 7.

Surgical terminations

For surgical terminations, you must complete the relevant dates and state the method used. An evacuation of retained products of conception is not a termination and should not be reported on an HSA4 form. If there is no overnight stay, only one date (the date of termination) needs to be given.

Medical terminations

If all medicines were administered in hospital or clinic

You must complete the relevant dates of treatment for antiprogesterone and prostaglandin.

If other medical agents were used, you must complete the relevant dates and state the agents used.

If completing the form for an early medical abortion (up to 9 weeks 6 days gestation), you must select all medicine administered in hospital or clinic for the question asking where the medicine was administered.

You must also complete the address box if the name and address of the place of treatment was different to the address shown at 4a. For example, if prostaglandin was administered at a different site to the address shown at 4a, you should state the name and address of the hospital or clinic in the box provided at 4d. You should leave the hospital or clinic code box empty.

If an overnight stay was required, you must fill in the date of discharge at 4c.

Where all medicine is administered in the hospital or clinic, you do not need to answer the questions asking whether any part of the consultation or treatment was provided face to face (in person) or which organisation provided the abortion.

If one medicine was administered in hospital or clinic and one medicine administered at the patient’s usual place of residence (home)

You must complete the relevant dates. You should state the advised treatment date(s) when medicine(s) for early medical abortion are prescribed, to be self-administered by the patient at their usual place of residence.

If the termination cannot be confirmed, you should leave the ‘date termination confirmed’ box blank. If, after sending the form, it is found that the pregnancy has not ended, a letter must be sent to the CMO and the form will be cancelled.

You must select ‘one medicine administered in hospital/clinic, one medicine administered at patient’s usual place of residence’ for the question asking where the medicine was administered.

Where medicines for early medical abortion were administered at patient’s usual place of residence, you must answer yes or no to indicate whether any part of the consultation and treatment was provided face to face by a registered medical practitioner, nurse or midwife. In this scenario, face to face means a physical (in-person) appointment rather than a remote teleconsultation. If you answered ‘no’ to this question, you may answer the optional question to indicate whether the patient was seen in person by another healthcare professional, such as a sonographer.

Where one medicine is administered in the hospital or clinic, you do not need to answer the question that asks which organisation provided the abortion.

If all medicines were administered at the patient’s usual place of residence (home):

You must complete the relevant dates. You should state the advised treatment date(s) when medicine(s) for early medical abortion is prescribed to be self-administered by the patient at their usual place of residence (home).

If the termination cannot be confirmed, you should leave the ‘date termination confirmed’ box blank. If, after sending the form, it is found that the pregnancy has not ended, a letter must be sent to the CMO and the form will be cancelled.

Where all medicine is administered at patient’s usual place of residence you do not need to complete the name and address of the place of treatment shown in 4a and 4d. You should leave the hospital/clinic code box empty.

You must select ‘All medicine administered at patient’s usual place of residence’ for the question asking where the medicine was administered.

Where medicines for early medical abortion were administered at patient’s usual place of residence, you must answer ‘yes’ or ‘no’ to indicate whether any part of the consultation and treatment was provided face to face by a registered medical practitioner, nurse or midwife. In this scenario, face to face means a physical (in-person) appointment rather than a remote teleconsultation. If you answered ‘no’ to this question, you may answer the optional question to indicate whether the patient was seen in person by another healthcare professional, such as a sonographer.

Where all medicines were self-administered by the patient at their usual place of residence, you can answer the optional question on which organisation provided the abortion. If your organisation is not listed, please select ‘other’ and state the name of your organisation.

Failed surgical or medical terminations

If a surgical or medical termination has failed (the fetus has not been expelled) and the procedure is repeated, you should complete one form only with both sets of dates on it, using page 7 to provide any extra information as necessary. If a form has already been sent and the termination is later found to have failed, you should complete a second form and return it with an accompanying letter stating this information.

Incomplete forms

Forms will be returned if no dates are given, if dates are invalid (for example, 30/02/2011), if dates are in the future or if dates given are deemed to be incorrect or inconsistent within the form (for example, date of prostaglandin is before date of antiprogesterone).

Section 5: gestation

For abortions at less than 24 weeks, you must give the number of completed weeks. For example, for abortions of 8 weeks plus 6 days, you should write ‘08’. For abortions at 24 weeks, you should also provide additional information. For example, for abortions at exactly 24 weeks, write ‘24 + 0’; for abortions at 24 weeks and 3 days, write ‘24 + 3’.

Forms will be returned if no gestation is provided, if gestation is less than 4 weeks or for additional information for gestations of over 24 weeks.

Section 6: grounds

You must select the grounds for terminating the pregnancy, as stated on HSA1. One or more ground(s) must be given.

In addition, you must select the following depending on which ground(s) was selected on the HSA1 or HSA2 form:

• grounds A or B – you should tick the relevant box and state the main medical condition
• ground C – you should tick the ‘yes’ box if there was a risk to the woman’s mental health; if the risk was to the woman’s physical health, you should tick ‘no’ and state the main medical condition
• ground D – you should tick the box
• ground E – you should state the fetal abnormality and the method of diagnosis, or other reason for termination, for example, a condition in pregnant woman causing suspected condition in the fetus
• grounds F or G – you should tick the relevant box and state the main medical condition

If the pregnancy was terminated after it had exceeded its 24th week, you must give a full statement of the medical condition of the pregnant woman and fetus.

Forms will be returned if any of the above information is missing.

A medical practitioner scrutinises all forms relating to terminations over 23 weeks and more information may be requested on a case-by-case basis.

Section 7: selective termination

You should only complete this section if the original number of fetuses was 2 or more and are reduced to 1 or more. All other relevant sections of the form also need to be completed.

A medical practitioner scrutinises all forms relating to selective terminations and more information may be requested on a case-by-case basis.

Section 8: chlamydia screening

You should tick the relevant box if women are offered screening or offered screening and prophylactic antibiotic treatment. The ‘yes’ box should not be ticked if prophylactic treatment alone is offered.

Section 9: complications

You must use this section to record any complications that occurred up until the time of discharge from the place of termination. Use page 7 to provide any extra information as necessary. You should not enter evacuations of retained products of conception or failed terminations (see section 4 of this guidance, above) as a complication.

A medical practitioner scrutinises all complications given in ‘other’ and more information may be requested on a case-by-case basis.

Section 10: death of woman

If a death occurs as a result of the termination, you must state the date and the cause of death.

A medical practitioner scrutinises all information given in this section and further information may be requested.

Submitting the form

The HSA4 form should be sent to the relevant address shown at the top of page 1 of the form within 14 days of the termination. Any forms with missing or inconsistent data will be returned to the clinician with the relevant parts of the form highlighted. These should be checked and amended as necessary and returned to DHSC. If the revised forms are not returned within 6 weeks, reminders will be sent every 2 months until the information is received.

Other information

Forms must be submitted within 14 days of the termination. Statistics are published quarterly and missing information affects the quality of these data outputs.

*[EMA}: early medical abortion