Improving paediatric tuberculosis and HIV clinical record keeping: the use of audit and a structured pro forma in a South African regional level hospital

Abstract

We report on the impact of revisions made to an existing pro forma facilitating routine assessment and the management of paediatric HIV and tuberculosis (TB) in KwaZulu-Natal, South Africa. An initial documentation audit in 2010 assessed 25 sets of case notes for the documentation of 16 select indicators based on national HIV and TB guidelines. Using the findings of this initial audit, the existing case note pro forma was revised. The introduction of the revised pro forma was accompanied by training and a similar repeat audit was undertaken in 2012. This demonstrated an overall improvement in documentation. The three indicators that improved most were documentation of maternal HIV status, child’s HIV status and child’s TB risk assessment (all P < 0.001). This study suggests that tailor-made documentation pro formas may have an important role to play in improving record keeping in low-resource settings.