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Improving Documentation Rates of Contraception and Reproductive Planning in Patients With Rheumatic Disease.

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Integrating a pre-visit questionnaire significantly improved rheumatology providers' documentation of contraception and reproductive planning for women of childbearing age. This enhancement in charting was sustained for six months.

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Area of Science:

  • Rheumatology
  • Reproductive Health
  • Health Informatics

Background:

  • Documentation of contraception and reproductive planning is crucial for women of childbearing age with rheumatic diseases, particularly those on teratogenic medications.
  • Rheumatology providers' notes often lack comprehensive documentation in this area.
  • Improving this documentation can lead to better patient counseling and outcomes.

Purpose of the Study:

  • To enhance the documentation of contraception and reproductive planning in rheumatology provider notes.
  • To assess the impact of an integrated electronic pre-visit questionnaire on this documentation.

Main Methods:

  • A retrospective chart review was conducted before and after implementing a reproductive health assessment questionnaire in the electronic health record.
  • Female patients aged 18-45 with autoimmune inflammatory rheumatic diseases were included.
  • Data on documentation rates, patient demographics, and encounter types were collected.

Main Results:

  • Provider documentation of contraception increased from 44.6% to 70.5% (p<0.0001).
  • Documentation of pregnancy planning rose from 15.5% to 60.2% (p<0.0001).
  • Improvements were significant for patients on teratogenic medications and were sustained for six months, unaffected by patient or provider demographics.

Conclusions:

  • An electronic, pre-visit questionnaire significantly improves rheumatology providers' documentation of contraception and pregnancy planning.
  • The positive impact on documentation was sustained for at least six months.
  • Further research is needed to determine if improved documentation correlates with enhanced reproductive healthcare discussions and outcomes.