Study Objective

Documentation of sexual orientation (SO) and gender identity (GI) is crucial to identify lesbian, gay, bisexual, and transgender youth and perform meaningful research to improve health disparities in this community. As a result, some electronic medical records (EMRs) have incorporated SO and GI into part of the provider's workflow for documentation. We aimed to evaluate the effect this modification has had on the frequency of SO and GI documentation.

Design, Setting, Participants, Interventions, and Main Outcome Measures

This was a retrospective chart review of patient encounters from an outpatient pediatric and adolescent gynecology clinical practice. The rate of documentation of SO and GI were compared between encounters that took place before the implementation of the EMR modification and those that took place after. Additionally, we examined rates of GI and SO documentation according to visit type and patient race.

Results

A statistically significant increase in the frequency of SO and GI documentation after the EMR modification was detected. The documentation rate of SO increased from 10/73 (13.7%) to 32/73 (45.1%) (P < .01) and GI documentation rate went from 1.4% to 46.5% (P < .01) after the EMR changes were implemented. SO or GI was most commonly documented in social history (90%). There were no differences in documentation on the basis of race or type of encounter.

Conclusion

Including a specific tab for SO and GI in the EMR significantly increased the frequency of SO and GI documentation. Despite this increase, frequency of documentation remained at less than 50%, emphasizing the need for further improvement.

中文翻译：

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电子病历修改后的性取向和性别认同文件的出现频率

研究目的

性取向（SO）和性别认同（GI）的文档对于识别女同性恋，男同性恋，双性恋和变性青年以及进行有意义的研究以改善该社区的健康差异至关重要。结果，一些电子病历（EMR）已将SO和GI纳入提供商的文档工作流程的一部分。我们旨在评估此修改对SO和GI文档的频率产生的影响。

设计，设置，参与者，干预措施和主要结果指标

这是回顾性图表回顾，回顾了来自门诊儿科和青少年妇科临床实践的患者。比较了在实施EMR修改之前和之后进行的SO和GI的文档生成率。此外，我们根据就诊类型和患者种族检查了GI和SO文档的比率。

结果

检测到EMR修改后，SO和GI文档记录的频率出现了统计上显着的增加。 在EMR变更后，SO的文档记录率从10/73（13.7％）增加到32/73（45.1％）（P  <.01），GI的文档记录率从1.4％增加到46.5％（P <.01）。实施的。SO或GI是社会历史上最常见的记录（90％）。根据种族或遭遇类型，文档上没有差异。

结论

在EMR中包含SO和GI的特定选项卡大大增加了SO和GI文档的频率。尽管增加了，但记录的频率仍不到50％，强调需要进一步改进。