A. A health professional who provides medical care or treatment to a woman who, in the good faith judgment of the health professional, is in need of medical care because of a complication or complications resulting from having undergone an abortion or attempted abortion must file a report with the department of health services on a form prescribed by the department. The report shall not identify the individual patient by name but must contain the following information and other information as the department may require:

1. 1. The date of the abortion.
2. 2. The woman's age.
3. 3. The number of pregnancies the woman may have had before the abortion.
4. 4. The number and type of abortions the woman may have had before this abortion.
5. 5. The name and address of the facility where the abortion was performed.
6. 6. The gestational age of the unborn child at the time of the abortion, if known.
7. 7. The type of abortion performed, if known.

8. 8. The nature of the complication or complications, including at least one of the following:

   1. (a) Shock.
   2. (b) Uterine perforation.
   3. (c) Cervical laceration requiring suture or repair.
   4. (d) Heavy bleeding or hemorrhage with estimated blood loss of at least five hundred cubic centimeters.
   5. (e) Aspiration or allergic response.
   6. (f) Postprocedure infection.
   7. (g) Sepsis.
   8. (h) Incomplete abortion retaining part of the fetus requiring reevacuation.
   9. (i) Damage to the uterus.
   10. (j) Failed termination of pregnancy.
   11. (k) Death of the patient.
   12. (l) Other.
9. 9. The medical treatment given.
10. 10. The nature and extent, if known, of any permanent condition caused by the complication.