In this study, we aimed to determine the frequency of menstrual history and sexual history documentation in the inpatient setting.
Design, Setting, and Participants
A retrospective chart review was conducted for 307 female patients ages 11-18 years admitted from the emergency department at a single institution within a 7-month period. These charts were reviewed for documentation of menstrual and sexual history.
Interventions and Main Outcome Measures
Rates of menstrual and sexual history documentation were compared according to patient age, chief complaint, admitting specialty, and medical complexity.
Sexual history documentation was noted in 158 (45.9%) of the 344 reviewed charts. Sexual history documentation rates were higher for patients with mental health symptoms (62.9%; 61 of 98 charts; P = .02) and lower for patients admitted to surgical services (30.6%; 19 of 62 charts; P = .04). At least 1 aspect of menses was documented in 113 (32.8%) of the 344 reviewed charts. Last menstrual period was the most commonly documented aspect of menstrual history, appearing in 100 (29.1%) of the 344 reviewed charts. Menarche (4.4%; 15/344), menses frequency (7.0%; 24/344), menses duration (2.6%; 9/344), flow quantity (4.9%; 17/344), and dysmenorrhea (4.4%; 15/344) were rarely documented, regardless of chief complaint or admitting service. Menstrual history documentation rates were significantly higher for patients requiring a gynecology consultation (73.3%; 11 of 15 charts; P < .01).
Menstrual and sexual history documentation rates for adolescent patients requiring inpatient admission were low, with fewer than half of patients having a documented menstrual or sexual history.
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Published online: May 20, 2019
The authors indicate no conflicts of interest.
These findings were presented, in part, at the 2017 Annual Clinical and Research Meeting of the North American Society of Pediatrics and Adolescent Gynecology in Chicago, Illinois, on April 20, 2017.
© 2019 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc.