Denise Cummins, Donna Waters, Christina Aggar, Catherine C O'Connor

To ascertain whether community-based health care providers were collecting appropriate information to identify patients at risk of HIV associated neurocognitive disorder and whether related documentation was complete. HIV associated neurocognitive disorder is a treatable neurological condition that can affect more than 20% of those infected with the HIV. Signs and symptoms of cognitive impairment may be subtle; therefore, documentation of medical and social information could be beneficial in identifying those at risk DESIGN: Cross sectional descriptive study. An audit of patient records was completed by two community-based interdisciplinary teams with particular attention to the documentation of clinical and social indicators for those at risk of HIV associated neurocognitive disorder. Data were collected over a four-week period during 2015. Data were retrieved from both electronic medical record systems and hard copy patient records. Documentation was incomplete in every patient record (N=262), including the absence of important clinical data relating to nadir CD4+T cell count (91%), HIV viral load (36%), current caregiver (19%) and living circumstances (14%). Up to 40% of recorded medications and results were unconfirmed by the person's medical practitioner. Poor documentation can lead to incomplete information, which can delay early intervention for those at risk of HIV associated neurocognitive disorder. Collection and recording of patient data needs to be consistent, as complete documentation is essential for integrating care, provision of clinical support and importantly, for identifying those at risk of developing HIV associated neurocognitive disorder. This article is protected by copyright. All rights reserved.