ANTENATAL TESTING FOR HIV ANTIBODY - PROBLEMS OF DOCUMENTATION AND RECORD

The objective of this study was to audit an ante-natal HN screening pr ogramme by observing the congruence of documentation of consent betwee n case notes and request forms; correlation of testing with prior agre ement to be tested; and recording documentation that the test had been offered but declined in women who were not tested. The design was one of retrospective case note review of 538 women drawn from an inner ci ty teaching hospital. There was documentation of invitation to undergo HIV testing in 415 (77%) cases. Test documentation was absent in 123 (23%) cases which represent 37% of those for whom a test was mot perfo rmed. HIV testing was performed in 205 (38%) cases. There was discrepa ncy between documentation of consent to testing on the laboratory requ est form and in the notes. Some blood specimens of women agreeing to b e tested were apparently never received in the laboratory. Incomplete documentation and a low test uptake suggests a low acceptance. However , without adequate documentation it cannot be determined in those not tested whether the test was declined or whether the invitation was eit her never extended, or not implemented after acceptance. Audit of impl ementation and staff compliance should be established at the outset a any universal testing programme.