An audit of completeness of HIV clinical histories: before and after introduction of an HIV proforma.
The completeness of a 'first consultation' human immunodeficiency virus (HIV) clinical history before and after the introduction of an HIV proforma was audited by a retrospective case notes review. Twenty key variables considered essential to every history were assessed. There was a significant improvement in the documentation of 14 of the 18 items for men and 14 of the 20 items for women post-proforma with no deterioration in documentation of any of the variables. Our study supports the introduction of a structured 'first consultation' notes proforma for use during consultations with both newly diagnosed HIV-positive patients and those transferring their care from other centres.
Natha
M
M
Department of GUM, St George's Healthcare NHS Trust, London, UK. macky_natha@yahoo.co.uk
Sheehy
C
C
Pollard
M
M
Pakianathan
M
M
Prime
K
K
D005260:Female; D015658:HIV Infections / Q000175:diagnosis*; D006801:Humans; D008297:Male; D008485:Medical Audit; D008487:Medical History Taking / Q000379:methods / Q000592:standards*; D008499:Medical Records; D012189:Retrospective Studies