An audit of completeness of HIV clinical histories: before and after introduction of an HIV proforma

Int J STD AIDS. 2008 Feb;19(2):127-8. doi: 10.1258/ijsa.2007.007174.

Abstract

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.

Publication types

  • Evaluation Study

MeSH terms

  • Female
  • HIV Infections / diagnosis*
  • Humans
  • Male
  • Medical Audit*
  • Medical History Taking / methods
  • Medical History Taking / standards*
  • Medical Records
  • Retrospective Studies