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Antenatal testing for HIV antibody: problems of documentation and record
F Dalzell1, A G Farkas, J Hawken
1Department of Obstetrics and Gynaecology, St Bartholomew's Hospital (Homerton), London, UK.
AIDS Care
|January 1, 1995
Summary
This audit of antenatal HIV screening found significant documentation gaps. Incomplete records hinder understanding of HIV test acceptance and refusal among pregnant women.
Area of Science:
- Medical Auditing
- Public Health
- Infectious Disease Screening
Background:
- Antenatal HIV screening is crucial for preventing mother-to-child transmission.
- Effective screening programs rely on accurate documentation and patient consent.
- Previous audits have highlighted documentation challenges in healthcare settings.
Purpose of the Study:
- To audit an antenatal human immunodeficiency virus (HIV) screening program.
- To assess the congruence of consent documentation between case notes and laboratory request forms.
- To evaluate the correlation between HIV testing and documented prior agreement, and to record instances where testing was offered but declined.
Main Methods:
- Retrospective case note review of 538 women at an inner-city teaching hospital.
- Analysis of documentation for invitation to test, consent, testing performed, and test refusal.
- Comparison of consent documentation in medical records versus laboratory request forms.
Main Results:
- Invitation for HIV testing was documented in 77% of cases (415/538).
- HIV testing was performed in 38% of cases (205/538).
- Discrepancies in consent documentation were noted; some specimens were not received by the lab, and test uptake was low.
Conclusions:
- Incomplete documentation and low uptake suggest potential issues with HIV test acceptance or program implementation.
- Accurate record-keeping is essential to determine if tests were declined or simply not offered/processed.
- Regular audits of implementation and staff compliance are recommended for universal HIV testing programs.
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