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.

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