International Journal of STD & AIDS > Volume 19, Number 2 > Pp. 127-128

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AUDIT REPORTS

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

M Natha MRCP ^* , C Sheehy RGN ^*, M Pollard BA , M Pakianathan FRCP ^* and K Prime MRCP ^*

^* Department of GUM; Department of Clinical Audit, St George's Healthcare NHS Trust, London, UK

Correspondence to: Dr M Natha Email: macky_natha{at}yahoo.co.uk

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.

Key Words: audit • clinical history • HIV • proforma

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