Audit of Gynecological History Documentation in Emergency Surgery
Author Information
Author(s): Muacevic Alexander, Adler John R, Siddiqui Asher, Jamal Zohaib, Zafar Nowera, Haider Muhammad Ijlal, Adnan Naqqash, Khawaja Zeeshan, Alam Imran
Primary Institution: Wrightington, Wigan and Leigh NHS Foundation Trust
Hypothesis
How complete and accurate is the documentation of gynecological history in female patients admitted for emergency surgery due to abdominal pain?
Conclusion
The audit revealed significant deficiencies in the documentation of key gynecological parameters in female patients with acute abdominal pain.
Supporting Evidence
- Only 14% of cases documented pregnancy status.
- 20% of cases documented contraceptive use.
- 50% of cases lacked documentation of gynecological history.
- 56% of cases lacked documentation of sexual history.
- An educational intervention improved documentation significantly.
Takeaway
Doctors need to ask more questions about women's health when they come in with stomach pain, especially about pregnancy, to keep them safe.
Methodology
A retrospective audit analyzing surgical assessment documents of 50 female patients aged 12-50 years admitted for emergency surgery.
Limitations
The study's small sample size and focus within a single NHS Trust limit the generalizability of the findings.
Participant Demographics
Female patients aged 12-50 years presenting with acute abdominal pain.
Statistical Information
P-Value
0.0004
Statistical Significance
p<0.05
Digital Object Identifier (DOI)
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