Residents should document sexual history during health care maintenance visits for older, asymptomatic adults
Clinicians need an accurate sexual history of patients in order to properly screen them for sexually transmitted infections (STIs) and to counsel them about safer sex, family planning, and sexual dysfunction. Yet, a new study shows that only about one-fourth of internal medicine residents documented the sexual history of patients during a routine health maintenance visit. Documentation was particularly low for older, asymptomatic patients.The researchers reviewed charts on health care maintenance visits conducted by internal medicine residents at two outpatient clinics affiliated with an academic medical center. These included reviews of 360 clinic notes in charts written by 26 residents. Only a quarter of all charts (25 percent) documented at least one component of a patient's sexual history—a mean percent by resident of 23 percent. Lack of documentation of sexual history was associated with patients 45 years and older compared with patients who were 18 to 25 years of age. When compared to patients documented as married, those with no documented marital status had a lower odds of having a documented sexual history.
Notably, Pap smears and prostate exams were not associated with documentation. Visits with patients with specific symptoms and complaints did have higher odds of having a documented sexual history. These symptoms include genitourinary or abdominal complaints, STI concerns, and the use of contraception. The study was supported in part by the Agency for Healthcare Research and Quality (HS19464).
See "Patient, resident physician, and visit factors associated with documentation of sexual history in the outpatient setting," by Danielle F. Loeb, M.D., Rita S. Lee, M.D., Ingrid A. Binswanger, M.D., and others in the Journal of General Internal Medicine 26(8), pp. 887-893, 2011.
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