Tool C: Client Record Review

Tool C examines the maintenance of clinical records and documentation of key VMMC care elements, including:  

  • Client record storage (on-site, secure, logically organized)
  • Client record forms (indicate if site has changed format in past 3 months)
  • Client details: Age, HIV status, informed consent, medical history and physical examination, date of surgery, name of surgeon, surgical method, anesthetic dosing, intra- and post-operative adverse events, follow-up visit
  • Additional details for PrePex: Method, device size and batch, dates of placement and removal, name of PrePex provider, adverse events at placement/removal/post-removal
  • SIMS: Check if client record form or VMMC register collects written documentation about post-operative follow-up visits

The process of applyng Tool C includes the following:

  • Review and observe client records (sample of 25)
  • If the site is implementing PrePex, review an additional 15 records specific to PrePex VMMC
  • Some of the SIMS questions require reviewing 10 of these client records
  • Interview staff responsible for records/data management

Systematic sampling is the preferred sampling method, especially if the site uses sequential numbering for client records. Use client record numbers rather than physical records for choosing records to review to provide an opportunity to determine whether any records are missing.  If a record number determined by the sample is missing, write "MISSING" in the cell for that client record.  To make a systematic sample, determine the number of male circumcisions (MCs) that have been performed at the site since the beginning of the VMMC program or since the last EQA visit to the site.  The cut-off period for the sample is at least 3 weeks prior to the date of the site visit.  Divide the number of MCs performed by 25 to calculate the sampling interval, N.  Request that staff pull every Nth client record for review.  If the site has changed its record forms longer than 3 months ago, restrict sampling to records filled since the chanage,

Provide comments for any missing/blank content.  Also verify the age for consent to VMMC in the country to verify that legal consent was given.

For the SIMS questions, pull 10 charts for review from the 25.  From the 10 records, calculate:

  • % of client records that include a consent form signed by the adult client or by the clien'ts guardian if the client is a minor
  • % of client records that include documentation of at least one post-operative follow-up visit within 14 days of the VMMC procedure

Among the clients without documentation of at least one post-operative follow-up visit within 14 days of the VMMC procedure, calculate the % of client records with documentation that active follow-up (by phone call or visit to the client's home, school or other off-site location) was attempted.

Pull 10 charts of HIV-positive clients referred for HIV care and treatment:

  • Calculate the % of clients that were successfully tracked (that is, the site knows the client was successfully linked to HIV care and treatment services)