Aim To improve the quality of care of children with headache by auditing history-taking and clinical examination based on evidence based guidelines in a district general hospital.
Method This was a retrospective quality improvement study with a closed loop re-audit. In the initial audit, 25 case notes were reviewed from both inpatient and outpatient settings. Inclusion criteria were children under the age of 17 and had headache as their primary presenting complaint. Documentation of history- taking and examination were compared against BPNA guidelines. A re-audit of 26 case notes was performed 6 months after the initial audit, similarly comparing documentation against guidelines.
Results In the initial audit of 25 patients, the average rate of documentation for history-taking across BPNA recommended domains was 62%, and documentation of clinical examination was 52%. For the history-taking domains, poor performing domains included intensity of symptoms (36%), quality of headache (36%) and triggers (44%). For clinical examination domains, the poor performing domains included examination of skin and scalp (8%) and pubertal status (8%).
The results were shared with the department at the monthly audit meeting and suggestions for history-taking and examination were made. A repeat quality improvement study was performed 6 months after the initial study. This showed a marked improvement in documentation of history-taking (76%, increase of 14%), and a marginal improvement in examination (53%, increase of 1%). For history-taking domains, there was an improvement across all domains with the exception of intensity of symptoms (31%). For clinical examination domains, there was a more varied performance with half the domains showing no improvement. In particular, there was no documented examination of pubertal status among all the cases we reviewed.
Conclusion Documentation of history-taking and examination is key because it determines subsequent management of patients. Our department demonstrated a good improvement in the documentation of history-taking, however more can be done to improve documentation of clinical examination. A BPNA proforma will be introduced to the department to improve documentation and a further audit will be repeated in 6 months to continue monitoring improvement.