Improving Confidential Documentation for Adolescents in the Emergency Department

Adolescents' health data for sexual/reproductive health, substance use, and mental health are legally confidential, and documenting this information appropriately prevents unintentional disclosure to caregivers via electronic health record (EHR) portals. This quality improvement project aimed to increase the percentage of confidential documentation from 5% to 10% in patients aged 12 to 17 years with positive suicide screens by January 2025.

At a 42-bed pediatric emergency department, we reviewed 6141 encounters between January 2022 and January 2025, including 2117 baseline visits (January 2022 to December 2022) and 4024 intervention-period visits (January 2023 to January 2025). Interventions included monthly education, a confidential history note in the EHR, and an adolescent social history flowsheet. The primary measure was the percentage of encounters with confidential documentation. Process measures included (1) use of separate confidential notes and (2) total adolescent flowsheet use per week. The balancing measure was caregiver complaints or requests related to missing information. P-charts and C-charts were analyzed using Nelson rules.

Confidential documentation increased from 5% to 15% over the study period. Use of separate confidential notes rose from 0% to 83% of protected notes, and total confidential notes increased from 4 to 15 per week across all adolescent encounters. No caregiver complaints were reported.

Embedding confidential note tools and targeted education increased compliance with best practices for adolescent confidentiality. EHR workflow integration and data segmentation improved privacy protections without negative feedback from caregivers.