Documentation of Gender Identity in an Adolescent and Young Adult Clinic

Abstract

PurposeTo determine if changing electronic health record (EHR) note templates can increase documentation of gender identity in an adolescent and young adult clinic. MethodsA 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. ResultsOne 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). ConclusionsThis 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.