Developing a preconception medical record audit tool for general practice: a multimethod study.

Nishadi N Withanage, Jessica R Botfield, Sharon James, Kirsten I Black, Sharon Cameron, Danielle Mazza
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Abstract

Background Preconception health risk factors documented in general practice electronic medical records help general practitioners (GPs) understand the proportion and type of risks among women attending their practice. We aimed to collaborate with GPs to develop an audit tool for collecting preconception health data from structured electronic medical record fields. Methods This was a three-phase multimethod study. In Phase 1, we developed a preliminary audit tool informed by the literature. In Phase 2, we collaborated with GPs for feedback. In Phase 3, we finalised the audit tool. Results The preliminary audit tool comprised 25 preconception health risk factors, of which three were removed following GP feedback (second-hand smoke, social history, history of sexually transmitted infections). The final audit tool comprised 22 preconception health risk factors. Conclusion This audit tool may assist researchers in understanding the proportion of patients visiting general practice with preconception health risk factors, thereby facilitating the future development of a screening process that may be used to identify and provide preconception care to women who may most benefit from it.

为全科实践开发孕前病历审核工具:一项多方法研究。
背景:在全科电子病历中记录的孕前健康风险因素有助于全科医生(gp)了解参加其实践的妇女的风险比例和类型。我们的目标是与全科医生合作开发一种审计工具,用于从结构化电子病历字段收集孕前健康数据。方法采用三期多方法研究。在第一阶段,我们根据文献开发了一个初步的审计工具。在第二阶段,我们与全科医生合作获得反馈。在第3阶段,我们完成了审计工具。结果初步审计工具共包含25个孕前健康危险因素,经全科医生反馈后剔除了3个因素(二手烟、社会史、性传播感染史)。最后的审计工具包括22个孕前健康风险因素。结论:该审计工具可帮助研究人员了解具有孕前健康风险因素的全科就诊患者的比例,从而促进筛查过程的未来发展,该筛查过程可用于识别并向可能从中受益最多的妇女提供孕前护理。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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