Stanley R Vance1, Veronika V Mesheriakova2. 1. Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, California. Electronic address: stanley.vance@ucsf.edu. 2. Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, California.
Abstract
PURPOSE: To determine if changing electronic health record (EHR) note templates can increase documentation of gender identity in an adolescent and young adult clinic. METHODS: A two-step gender question was added to EHR note templates for physicals in February 2016. A retrospective chart review was performed 3 months before and after this addition. The primary measure was whether answers to the two-step question were documented. Gender identity/birth-assigned sex discordance, age, and use of the appropriate note template post-template change were also measured. RESULTS: One hundred twenty-five pretemplate change and 106 post-template change physicals were reviewed with an inter-rater reliability of 97%. Documentation of answers to the two-step gender identity question increased from 11% to 84% (p < .001). CONCLUSIONS: This study suggests that incorporating a standardized question into EHR note templates is effective at improving the documentation of gender identity in youth presenting for annual physicals.
PURPOSE: To determine if changing electronic health record (EHR) note templates can increase documentation of gender identity in an adolescent and young adult clinic. METHODS: A two-step gender question was added to EHR note templates for physicals in February 2016. A retrospective chart review was performed 3 months before and after this addition. The primary measure was whether answers to the two-step question were documented. Gender identity/birth-assigned sex discordance, age, and use of the appropriate note template post-template change were also measured. RESULTS: One hundred twenty-five pretemplate change and 106 post-template change physicals were reviewed with an inter-rater reliability of 97%. Documentation of answers to the two-step gender identity question increased from 11% to 84% (p < .001). CONCLUSIONS: This study suggests that incorporating a standardized question into EHR note templates is effective at improving the documentation of gender identity in youth presenting for annual physicals.
Authors: Hilary Goldhammer; Chris Grasso; Sabra L Katz-Wise; Katharine Thomson; Allegra R Gordon; Alex S Keuroghlian Journal: J Am Med Inform Assoc Date: 2022-06-14 Impact factor: 7.942