An Audit Cycle of Gynecological History Documentation in Emergency Surgical Admissions of Female Patients of Childbearing Age Presenting with Acute Abdominal Pain at a District General Hospital.

Abstract

Background Ectopic pregnancy (EP) is a significant cause of maternal morbidity and mortality. Accurate and timely diagnosis is crucial, particularly in women of reproductive age presenting with acute abdominal pain. This audit aimed to assess the completeness and accuracy of gynecological history documentation, including pregnancy status, in female patients admitted for emergency surgery due to abdominal pain. Methods A retrospective audit was conducted within a single NHS Trust, analyzing the surgical assessment documents of 50 female patients aged 12-50 years admitted for emergency surgery. Data collected included documentation of pregnancy status, gynecological history, last menstrual period, sexual activity, and contraceptive use. A subsequent audit cycle assessed the impact of an educational intervention on documentation practices. Results Initial findings revealed significant deficiencies in the documentation of key gynecological parameters. Pregnancy status was documented in only 14% of cases, and contraceptive use in 20%. A substantial proportion of cases lacked documentation of gynecological history 50% and sexual history 56%. An educational intervention resulted in a significant improvement in the documentation of sexual history, contraceptive use, and pregnancy status. Conclusion This audit revealed significant deficiencies in the initial gynecological assessment of female patients with acute abdominal pain, particularly regarding the documentation of pregnancy status, menstrual history, and contraceptive use. The study highlights the need for improved clinical practices, including enhanced medical education, standardized assessment protocols, and electronic documentation of pregnancy status. Continued research is crucial to address these deficiencies and optimize patient care within the NHS.