Goenka Anu, Annamalai Medeshni, Dhada Barnesh, Stephen Cindy R, McKerrow Neil H, Patrick Mark E
Clinical Research Fellow, Manchester Collaborative Centre for Inflammation Research, University of Manchester, UK.
Trop Doct. 2014 Apr;44(2):96-9. doi: 10.1177/0049475513515477. Epub 2013 Dec 5.
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.
我们报告了对一份现有预编报表进行修订所产生的影响，该报表有助于南非夸祖鲁-纳塔尔省对儿科艾滋病毒和结核病进行常规评估及管理。2010年的首次文件审核依据国家艾滋病毒和结核病指南，对25套病例记录中的16项选定指标的记录情况进行了评估。利用首次审核的结果，对现有的病例记录预编报表进行了修订。修订后的预编报表推出时伴有培训，并于2012年进行了类似的重复审核。这表明文件记录有了总体改善。改善最为显著的三项指标是孕产妇艾滋病毒感染状况记录、儿童艾滋病毒感染状况记录以及儿童结核病风险评估（所有P值均<0.001）。本研究表明，量身定制的文件记录预编报表可能在改善资源匮乏地区的记录保存方面发挥重要作用。
