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Documentation of preoperative counselling for female sterilisation: a complete audit cycle.

Anderson J, Gunn E, Hunter M, Owen P

Department of Gynaecology, Stobhill Hospital, Glasgow, UK.

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%.

Published 21 February 2005 in J Fam Plann Reprod Health Care, 31(1): 24-5.
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