Frequency of Sexual Orientation and Gender Identity Documentation After Electronic Medical Record Modification

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.

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.

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.