An audit of completeness of clinical histories: before and after introduction of a pro forma.
The completeness of a random sample of medical records, before and after introduction of a pro forma, was measured in an audit. Twenty key variables that were considered as an essential part of every clinical history were assessed. There was a significant improvement in nine of the 18 items for men, and 11 of the 20 items for women. The mean completeness score increased from 14.5 to 15.9 (out of 18) in men, and from 15 to 17.5 (out of 20) in women (P < 0.001). The improved completeness of medical records as a result of the pro forma should result in the improved management of clients, in addition to providing improved documentation in the case of a medicolegal case.
Schmidt
Martina
M
Melbourne Sexual Health Centre, 580 Swanston Street, Carlton, Victoria 3053, Australia.
Rizvi
Nilofar
N
Lee
David M
DM
Wood
Vanessa
V
Amisano
Suzanne
S
Fairley
Christopher K
CK
D004282:Documentation / Q000379:methods* / Q000592:standards*; D006801:Humans; D008485:Medical Audit; D008487:Medical History Taking; D008499:Medical Records / Q000592:standards*; D008501:Medical Records, Problem-Oriented; D009741:Nursing Staff, Hospital / Q000592:standards