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

INTRODUCTION

The Courtyard Clinic, St George's hospital, is a large south-west London teaching hospital with a cohort of over 1000 human immunodeficiency virus (HIV)-positive patients. There are approximately 10 new HIV-positive patient diagnoses per month in the clinic. Health care professionals (HCPs) are required to keep clear, legible and contemporaneous notes. The use of a structured proforma for clinical history taking has been shown to result in improved data collection and patient care. ¹ History-taking and discussion during the first consultation with a new HIV-positive patient (either newly diagnosed or transferring their care to the clinic) is particularly suited to a notes proforma. This allows important information on baseline blood tests, medical, psychological and social history to be captured in a structured way in addition to prompting discussion on specific issues such as CD4/viral load significance, antiretroviral therapy, HIV natural history, partner notification, condom use, availability of post-exposure prophylaxis and permission for general practitioner correspondence. Our aim was to see if the implementation of a ‘first consultation’ notes proforma resulted in improved quality and completeness of medical records in addition to prompting discussion on specific issues relating to new HIV-positive patients.

METHODS

In October 2005, following a period of extensive consultation and a small pilot study, the clinic adopted a ‘first consultation’ notes proforma for use during consultations with new HIV positive patients. A designated space was provided for recording up to 20 variables including results of baseline blood tests and specific answers relating to the medical, psychological and social history. Two variables (Communicable Disease Surveillance Centre [CDSC] form and resistance test) were not included for patients transferring their care from other centres. Prompts were also included to encourage discussion on various issues specific to new HIV-positive patients. The colour of the proforma was changed from white to pink so it would be easily identifiable in a large set of notes. Prior to this date, data collection and recording of discussions between HCPs and patients was not formatted and the completeness of the baseline information recorded varied between individual clinicians.

The first consultation entries of 100 randomly selected medical notes of new HIV-positive patients were each assessed by two individuals (M.N. and C.S.); 50 who presented for their first consultation pre-proforma, between October 2004 and October 2005 and a further 50 presenting post-proforma, between October 2005 and October 2006. Each clinical record was scored for 18 items in men and 20 items in women that were considered essential for all ‘first consultation’ HIV-positive patients. HCPs at the clinic were unaware that the audit was taking place.

RESULTS

Twelve separate clinicians were responsible for filling out the 100 proformas sampled. Of the 50 pre-proforma patients, there were 25 men and 25 women. There were 35 men and 15 women in the post-proforma group. Table 1 shows the 20 variables examined, with documentation rates pre- and post- introduction of the notes proforma. 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 in any of the variables.

DISCUSSION

Our audit showed an improvement in documentation of most of the variables listed following the introduction of a structured notes proforma. This has been a simple and cost-neutral measure to implement, resulting in improved consistency of data collection among the many HCPs working in the clinic. It has also resulted in the potential for less litigation against clinicians due to improvements in documentation of discussion around partner notification, PEP and condom use. In addition, with many patients also transferring their care to other centres, including asylum seeker dispersal programmes, ² the new proforma provides clinicians with a clear record of the patient's first visit, which enhances communication between health professionals.

Although proformas are commonly used, we were only able to identify two published studies evaluating the use of a proforma in a sexual health setting. ^1,3 The study by Prime et al. ³ looking at the use of proformas in HIV-positive women, showed improvements in documentation of discussion of cervical smear outcomes, sexual activity, contraceptive use, pregnancy plans and screening for sexually transmitted infections, post-introduction of a notes proforma. The study by Schmidt et al. ¹ also supported our results with a significant improvement in nine of the 18 variables for men, and 11 of the 20 variables for women after the introduction of a notes proforma. Our study is also consistent with a number of studies outside the sexual health setting, which also resulted in marked improvements in documentation in the medical records. ⁴

The weakness of this audit was that it was based on a ‘before and after’ design and other factors may have been responsible for the improvement in the documentation after introduction of the proforma. To minimize bias, we did not inform clinicians that the audit was taking place.

CONCLUSION

Our study supports the introduction of a ‘first consultation’ notes proforma for use during consultations with both newly diagnosed HIV-positive patients and those transferring their care from other centres. This is a cost-neutral measure resulting in significant improvements in the documentation of baseline blood tests, medical, psychological and social history in addition to prompting discussion on issues specific to these patients including safe sex and availability of post-exposure prophylaxis following sexual exposure (PEPSE). Repeating the audit at a later date would be a useful exercise to support reproducibility of our results.