@article{ref1,
title="Documentation of gender identity in an adolescent and young adult clinic",
journal="Journal of Adolescent Health",
year="2016",
author="Vance, Stanley R. and Mesheriakova, Veronika V.",
volume="60",
number="3",
pages="350-352",
abstract="PURPOSE: To determine if changing electronic health record (EHR) note templates can increase documentation of gender identity in an adolescent and young adult clinic. <br><br>METHODS: A 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. <br><br>RESULTS: One 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). <br><br>CONCLUSIONS: This 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.<br><br>Copyright © 2016 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.<p /> <p>Language: en</p>",
language="en",
issn="1054-139X",
doi="10.1016/j.jadohealth.2016.10.018",
url="http://dx.doi.org/10.1016/j.jadohealth.2016.10.018"
}