Developing a preconception medical record audit tool for general practice: a multimethod study

Nishadi N. Withanage; Jessica R. Botfield; Sharon James; Kirsten I. Black; Sharon Cameron; Danielle Mazza

doi:10.1071/PY24132

RESEARCH ARTICLE (Open Access)

Developing a preconception medical record audit tool for general practice: a multimethod study

Nishadi N. Withanage ^A ^B ^* , Jessica R. Botfield ^A ^B , Sharon James ^A ^B , Kirsten I. Black ^B ^C , Sharon Cameron ^D Danielle Mazza ^A ^B

+ Author Affiliations

- Author Affiliations

^A Department of General Practice, Monash University, Melbourne, Vic, Australia.

^B SPHERE NHMRC Centre of Research Excellence, Melbourne, Vic, Australia.

^C The University of Sydney, Sydney, NSW, Australia.

^D University of Edinburgh, Scotland, UK.

^* Correspondence to: nishadi.withanage@monash.edu

Australian Journal of Primary Health 31, PY24132 https://doi.org/10.1071/PY24132

Submitted: 22 August 2024 Accepted: 6 March 2025 Published: 24 March 2025

© 2025 The Author(s) (or their employer(s)). Published by CSIRO Publishing on behalf of La Trobe University. This is an open access article distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND)

Abstract

Background

Preconception health risk factors documented in general practice electronic medical records help general practitioners (GPs) understand the proportion and type of risks among women attending their practice. We aimed to collaborate with GPs to develop an audit tool for collecting preconception health data from structured electronic medical record fields.

Methods

This was a three-phase multimethod study. In Phase 1, we developed a preliminary audit tool informed by the literature. In Phase 2, we collaborated with GPs for feedback. In Phase 3, we finalised the audit tool.

Results

The preliminary audit tool comprised 25 preconception health risk factors, of which three were removed following GP feedback (second-hand smoke, social history, history of sexually transmitted infections). The final audit tool comprised 22 preconception health risk factors.

Conclusion

This audit tool may assist researchers in understanding the proportion of patients visiting general practice with preconception health risk factors, thereby facilitating the future development of a screening process that may be used to identify and provide preconception care to women who may most benefit from it.

Keywords: audit, general practice, medical records, preconception care, pre-pregnancy care, primary care, reproductive age, women.

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