An audit of completeness of HIV clinical histories: before and after introduction of an HIV proforma.

The completeness of a 'first consultation' human immunodeficiency virus (HIV) clinical history before and after the introduction of an HIV proforma was audited by a retrospective case notes review. Twenty key variables considered essential to every history were assessed. There was a significant improvement in the documentation of 14 of the 18 items for men and 14 of the 20 items for women post-proforma with no deterioration in documentation of any of the variables. Our study supports the introduction of a structured 'first consultation' notes proforma for use during consultations with both newly diagnosed HIV-positive patients and those transferring their care from other centres.