Fertility History: Assessment of Performance and Quality Improvement

Abstract

Background: Many fertility clinics use their own standard history sheet. Currently, no standard history sheet is in use in our unit. This audit project aimed at assessing the quality of the history obtained from couples with sub-fertility without using a standard history sheet followed by designing and introducing a standardized history sheet and re-auditing the quality of the history obtained to assess if introducing a standardized history sheet into our unit will improve the quality of the service provided.

Methods: We started by designing a standardized history sheet which is simple, non-time consuming and contains all the basic information required at that very early stage of managing couples with sub-fertility. Data were collected from 50 notes retrospectively where we made sure that the notes included were for patients seen by different registrars at their first consultation. The standardized sheet was then introduced and all doctors were asked to use it for history taking during the first consultation with new couples seen in the clinic. Data were then collected from 50 notes where the standardized sheet was used.

Results: The quality of the history taken at the first consultation is inconsistent and variable. The quality may be improved if a simple form of standard history sheet is used by all doctors doing the fertility clinic.

Conclusion: History taking is a fundamental step in the management of sub-fertile couples. Couples complaining of sub-fertility will have their history taken during their first consultation at the reproductive medicine clinic. As the gynecology trainees running the clinic can be alternating, the quality of the history taken from these patients can vary. Obtaining accurate and complete information will help in making the management of those patients a smoother process with reducing the number of consultations and increasing patient satisfaction.




J Clin Gynecol Obstet. 2016;5(3):77-80
doi: http://dx.doi.org/10.14740/jcgo411w