Purpose

We sought to evaluate sexual history documentation and corresponding Chlamydia trachomatis screening practices across a large pediatric primary care network in the context of patient and clinic characteristics.

Methods

Demographic, chlamydia screening, and provider note data were collected via electronic health record and manual chart audit for females aged 15-19 years attending annual well-adolescent visits, from February 1 to 28, 2019. Inductive qualitative textual analysis evaluated sexual history documentation as informative (containing clear indication of patient as sexually active or not) or noninformative and identified documentation subtypes. We examined patient and clinic characteristics by sexual history documentation type (informative or noninformative) and chlamydia screening status and documentation subtypes across clinic types using chi-square and Fisher’s exact tests. A multilevel logistic regression model considering clinic-specific random effects evaluated predictors of informative sexual history documentation.

Results

Chart notes were examined for 1,062 patients across 31 unique clinics. Only 34.7% of chart notes were found to have informative sexual history documentation. Older patients (odds ratio: 1.51, 95% confidence interval: 0.99-2.31) and patients seen at clinics receiving U.S. Department of Health and Human Services Title-X funding (odds ratio: 11.05, 95% confidence interval: 1.34-90.86) had higher rates of informative documentation. The overall Chlamydia screening rate was 13.1%.

Conclusion

Sexual history documentation varied widely across clinics, and the majority of chart notes were found to have noninformative documentation. Understanding and addressing barriers to informative sexual history documentation and comprehensive sexual health care is fundamental to improve adolescent sexual health outcomes, particularly given recently enacted federal electronic health record transparency policies.

中文翻译：

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初级保健电子健康记录系统中性史文件的变异性

目的

我们试图在患者和临床特征的背景下评估性史文件和相应的沙眼衣原体筛查实践。

方法

2019 年 2 月 1 日至 28 日，通过电子健康记录和手动图表审计收集了参加年度健康青少年访问的 15-19 岁女性的人口统计数据、衣原体筛查和提供者记录数据。归纳定性文本分析将性史记录评估为信息性（包含患者性活跃与否的明确指示）或非信息性和已识别的文档子类型。我们使用卡方检验和 Fisher 精确检验，按性史文件类型（信息性或非信息性）和衣原体筛查状态以及跨诊所类型的文件亚型检查患者和诊所特征。考虑临床特定随机效应的多级逻辑回归模型评估了信息性历史文档的预测因子。

结果

检查了 31 个独特诊所的 1,062 名患者的图表注释。只有 34.7% 的图表注释被发现具有信息丰富的性史文件。老年患者（比值比：1.51，95% 置信区间：0.99-2.31）和在接受美国卫生与公众服务部 Title-X 资助的诊所就诊的患者（比值比：11.05，95% 置信区间：1.34-90.86）有信息文档率更高。总体衣原体筛查率为13.1%。

结论

性史文件在诊所之间差异很大，并且发现大多数图表注释都没有提供信息的文件。了解和解决信息性历史记录和全面性保健的障碍对于改善青少年性健康结果至关重要，特别是考虑到最近颁布的联邦电子健康记录透明度政策。