It's not in the notes!

Background: Minor neurocognitive disorder (MND) may be difficult to identify, as key symptoms can be due to other clinical conditions, such as depression. Using a client self assessment booklet, HIV associated MND (mild neurocognitive disorder). How to recognise the signs and symptoms, we recruited 123 participants from three clinical sites: an inner metropolitan hospital-based HIV clinic, an inner metropolitan sexual health clinic, and a suburban hospital-based HIV clinic in Sydney, Australia. A medical record audit was conducted to ascertain whether signs and symptoms (S&S) of MND, identified by the patient and/or their nominated caregiver, were discussed at their following medical consultation. Although the medical record may not reflect the medical consultation, a lack of documentation may indicate of the lack of importance the doctor may have placed on the issue at the time. We assumed, in the absence of documentation, that there had been no discussion of the issue with the patient regarding the symptoms reported, and that no follow-up would occur. Methods: Using the booklet, patients and/or their nominated caregivers identified S&S of MND. A list was generated of their specific S&S and was placed in their medical record as a reminder for the doctor and to aid discussion at the patient’s next medical consultation. An audit of the clinical files was then conducted, focusing on the next three medical appointments to ascertain whether there was documentation regarding discussion with patients about their S&S and if follow-up or investigation was mentioned. Results: One hundred and twenty-three patients and 43 caregivers were recruited across three sites. Of these, 92 patients and 30 caregivers (73%) selected four or more S&S. Documentation of discussion regarding these results with the patient was as follows: at the inner metropolitan hospital-based HIV clinic, 26%; at the inner metropolitan sexual health clinic, 43%; and at the suburban hospital-based HIV clinic, where there was no documentation in any notes, 0%. This gave an average of 26% across the three sites.