Female sterilization is a commonly performed gynecological procedure that attracts a disproportionate number of complaints and litigation. Documentation of the critical counseling issues provides an essential record of the woman’s information before undergoing sterilization.
Auditable standards were obtained from published guidelines. After the initial audit of 100 cases, a proforma was introduced to improve documentation. A re-audit of 50 subjects was undertaken to ascertain compliance of documentation following the introduction of the proforma.
The proforma was used in 62% of cases, and in all such cases, documentation was 100% compliant with the auditable standards. Overall, documentation of standards pre- and post-proforma, respectively, was as follows (all the figures quoted are percentage values, with the range given in parentheses): 33 (24–43) vs. 68 (53–80) for long-term alternatives, 94 (87–98) vs. 78 (62–87) for irreversibility, 96 (90–99) vs. 78 (64–88) for failure rate, 48 (38–58) vs. 66 (51–79) for ectopic pregnancy risk if sterilization fails, 39 (29–49) vs. 66 (51–79) for the intended method, 67 (57–76) vs. 66 (51–79) for operative risks and 37 (28–47) vs. 64 (49–77) for continuing current contraception until sterilization performed.
Documentation of preoperative counseling for female sterilization is often incomplete and does not comply with published recommendations. The introduction of a proforma resulted in a mixture of both improvement and deterioration of documentation. When the proforma was used, compliance with recommendations was 100%.