Documentation of preoperative counselling for female sterilisation: a complete audit cycle
Documentation of preoperative counselling for female sterilisation: a complete audit cycle
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女性绝育术前咨询记录：完整的审核周期
DOI：
10.1783/0000000052972816
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发表时间：
2005
影响因子：
--
通讯作者：
P. Owen
中科院分区：
文献类型：
--
作者：
Judy Anderson;E. Gunn;Mandy Hunter;P. Owen
女性绝育手术是一种常见的妇科手术，引起了不成比例的投诉和诉讼。关键咨询问题的文件提供了在绝育前向妇女提供的信息的重要记录方法审计标准是从已公布的指导方针中获得的。在对100个案件进行初步审计后，采用了一种形式，以改进文件编制。对50个案件进行了重新审计，以确定采用形式表格后文件是否符合规定。结果62%的病例使用了形式文件，所有病例的文件100%符合审计标准。总的来说，标准的预估和预估后的文件分别如下（所有引用的数字都是百分比值，范围在括号内给出）：长期替代方案33 (24-43)vs 68(53-80)，不可逆性94 (87-98)vs 78(62-87)，失败率96 (90-99)vs 78(64 - 88)，绝育失败后异位妊娠风险48 (38-58)vs 66(51-79)，预期方法39 (29-49)vs 66(51-79)，手术风险67 (57-76)vs 66(51-79)，继续当前避孕直到绝育的37 (28-47)vs 64（49-77）。结论：女性绝育术前咨询的文献资料往往不完整，不符合已发表的建议。形式表的引入导致了文件的改进和恶化。当使用形式表时，对建议的遵从率为100%。
Background Female sterilisation is a commonly performed gynaecological procedure that attracts a disproportionate number of complaints and litigation. Documentation of the key counselling issues provides an important record of the information given to the woman prior to undergoing sterilisation Methods Auditable standards were obtained from published guidelines. After the initial audit of 100 cases a proforma was introduced in an effort to improve documentation. A re-audit of 50 cases was undertaken to ascertain compliance of documentation following the introduction of the proforma. Results The proforma was used in 62% of cases and in all such cases documentation was 100% compliant with the auditable standards. Overall, documentation of standards pre- and post-proforma, respectively, was as follows (all the figures quoted are percentage values, with the range given in parentheses): 33 (24–43) vs 68 (53–80) for long-term alternatives, 94 (87–98) vs 78 (62–87) for irreversibility, 96 (90–99) vs 78 (64–88) for failure rate, 48 (38–58) vs 66 (51–79) for ectopic pregnancy risk if sterilisation fails, 39 (29–49) vs 66 (51–79) for the intended method, 67 (57–76) vs 66 (51–79) for operative risks and 37 (28–47) vs 64 (49–77) for continuing current contraception until sterilisation performed. Conclusions Documentation of preoperative counselling for female sterilisation is often incomplete and does not comply with published recommendations. The introduction of a proforma resulted in a mixture of both improvement and deterioration of documentation. When the proforma was used, compliance with recommendations was 100%.