Objective: To determine if the documentation for intrauterine device (IUD) insertions was satisfactory and to agree minimum standards for practice.
Method: A list was drawn up with minimum standards for documentation in the case notes. These were agreed at the clinical audit meeting. A retrospective analysis of case notes was done and a list completed for each IUD insertion.
Setting and participants: IUD fittings at all the Abacus clinics from 1 September 1999 to 31 October 1999.
Results: Of the 232 IUD insertions, the gold standard for documentation was met in 20%, however documentation of essential criteria was met 93% and all criteria 83% of the time. Each doctor received individual, confidential, comparative feedback.
Conclusion: We were able to agree a minimum standard for documentation to enhance adequate counselling, safe insertion, communication with colleagues and risk management.