title: Documentation of Pregnancy Status, Gynaecological History, Date of Last Menstrual Period and Contraception Use in Emergency Surgical Admissions: Time for a Change in Practice?
abstract: OBJECTIVE
  To determine whether pregnancy status, gynaecological history, date of last menstrual period and contraceptive use are documented in emergency female admissions of reproductive age admitted to general surgery.
  
  
  METHODS
  This is a retrospective study.
  
  
  METHODS
  This study was conducted in the United Kingdom.
  
  
  METHODS
  Females of reproductive age (12-50 years) admitted as an emergency to general surgery with abdominal pain were considered in this study.
  
  
  METHODS
  Retrospective analysis of medical notes of emergency female admissions with abdominal pain between January and September 2012. We recorded whether a pregnancy test result was documented (cycle 1). Results were analysed and a prompt added to the medical clerk-in document. We re-audited (cycle 2) between January and June 2013 looking for improvement.
  
  
  METHODS
  Documented pregnancy status within 24 h of admission and prior to any surgical intervention.
  
  
  RESULTS
  100 case notes were reviewed in stage 1. 30 patients (30 %) had a documented pregnancy status. 32 (32 %), 25 (25 %) and 29 (29 %) had a documented gynaecology history, contraceptive use and date of last menstrual period (LMP), respectively. 24 patients underwent emergency surgery, 6 (25 %) had a documented pregnancy status prior to surgery. Of 50 patients reviewed in stage 2, 37 (75.0 %) had a documented pregnancy status (p < 0.001), with 41 (82 %) having both gynaecological history (p < 0.0001) and contraceptive use (p < 0.0001) documented. 40 patients (80 % had a documented LMP (p < 0.0001). 7 patients required surgery, of whom 6 (85.7 %) had a documented pregnancy test prior to surgery (p = 0.001). All pregnancy tests were negative.
  
  
  CONCLUSIONS
  A simple prompt in the surgical admission document has significantly improved the documentation of pregnancy status and gynaecological history in our female patients, particularly in those who require surgical intervention. A number of patient safety concerns were addressed locally, but require a coordinated, interdisciplinary discussion and a national guideline. A minimum standard of care, in females of reproductive age, should include mandatory objective documentation of pregnancy status, whether or not they require surgical intervention.
authors: NHS Lothian, Edinburgh, UK.
authors: M
authors: M
authors: Powell-Bowns
authors: Ninewells Hospital, NHS Tayside, Dundee, DD1 9SY, UK. michaelwilson3@nhs.net.
authors: M S J
authors: http://orcid.org/0000-0003-1083-4466
authors: MS
authors: Wilson
authors: NHS Borders, Melrose, UK.
authors: A
authors: A
authors: Mustafa
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D003267:Contraception / Q000379:methods; D004282:Documentation; D004630:Emergencies; D005260:Female; D006760:Hospitalization; D006801:Humans; D008499:Medical Records; D008875:Middle Aged; D010343:Patient Admission; D018579:Patient Selection; D011247:Pregnancy; D011258:Pregnancy Tests; D017584:Reproductive History; D012189:Retrospective Studies; D013514:Surgical Procedures, Operative / Q000379:methods* / Q000592:standards*; D006113:United Kingdom; D055815:Young Adult