Documentation of Pregnancy Status, Gynaecological History, Date of Last Menstrual Period and Contraception Use in Emergency Surgical Admissions: Time for a Change in Practice?

Objective To determine whether pregnancy status, gynaecological history, date of last menstrual period and contraceptive use are documented in emergency female admissions of reproductive age admitted to general surgery. Design This is a retrospective study. Setting This study was conducted in the United Kingdom. Population Females of reproductive age (12–50 years) admitted as an emergency to general surgery with abdominal pain were considered in this study. Methods Retrospective analysis of medical notes of emergency female admissions with abdominal pain between January and September 2012. We recorded whether a pregnancy test result was documented (cycle 1). Results were analysed and a prompt added to the medical clerk-in document. We re-audited (cycle 2) between January and June 2013 looking for improvement. Main outcome measures Documented pregnancy status within 24 h of admission and prior to any surgical intervention. Results 100 case notes were reviewed in stage 1. 30 patients (30 %) had a documented pregnancy status. 32 (32 %), 25 (25 %) and 29 (29 %) had a documented gynaecology history, contraceptive use and date of last menstrual period (LMP), respectively. 24 patients underwent emergency surgery, 6 (25 %) had a documented pregnancy status prior to surgery. Of 50 patients reviewed in stage 2, 37 (75.0 %) had a documented pregnancy status ( p