The Need for Standardized Nomenclature in Electronic Documentation of Female Genital Cutting in Health Records

IF 2 4区 医学 Q3 PUBLIC, ENVIRONMENTAL & OCCUPATIONAL HEALTH
Jae Creger, Kalthum Abdikeir, Kyra Kaczmarczik, Nicole Chaisson, Crista E. Johnson-Agbakwu, Beatrice “Bean” E. Robinson, Jennifer Jo Connor
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Abstract

To evaluate the quality of Electronic Health Record (EHR) documentation practices of Female Genital Cutting (FGC) by medical providers. A retrospective chart review study of 99 patient encounter notes within the University of Minnesota health system (inclusive of 40 hospitals and clinics) was conducted. Extracted data included but was not limited to patient demographics, reason for patient visit, ICD code used in note, and provider description of FGC anatomy. Data was entered into REDCAP and categorized according to descriptive statistics. Out of 99 encounters, 45% used the unspecified code for FGC. The most common reason for patient visits was sexual pain, though many notes contained several reasons for the visit regarding reproductive, urological, or sexual concerns. 56% of visits discussed deinfibulation. 11 different terms for FGC were used, with “female circumcision” being the most common. 14 different terms for deinfibulation were found within 64 notes. 42% of encounters included a description of introitus size in the anatomical description, and only 38% of these provided a metric measurement. This study found significant variation in the quality of FGC documentation practices. Medical providers often used the unspecified FGC code, subjective and/or seemingly inaccurate descriptions of FGC/anatomy, and several different terms for both FGC and deinfibulation. Clearly, more education is needed in clinical training programs to (1) identify FGC type, (2) use the corresponding ICD code, and (3) use specific, objective descriptions (including presence/absence of structures and infibulation status).

健康记录中切割女性生殖器官的电子文档需要标准化术语
目的:评估医疗服务提供者有关切割女性生殖器官(FGC)的电子病历(EHR)记录质量。我们对明尼苏达大学医疗系统(包括 40 家医院和诊所)内的 99 份患者就诊记录进行了回顾性病历审查研究。提取的数据包括但不限于患者人口统计学特征、患者就诊原因、病历中使用的 ICD 代码以及医疗服务提供者对 FGC 解剖的描述。数据被输入 REDCAP,并根据描述性统计进行分类。在 99 次就诊中,45% 使用了未指定的 FGC 代码。患者就诊的最常见原因是性疼痛,尽管许多病例记录中包含多个就诊原因,涉及生殖、泌尿或性方面的问题。56%的就诊者讨论了脱肛问题。使用了 11 种不同的术语来描述女性割礼,其中 "女性包皮环切术 "最为常见。在 64 份记录中发现了 14 个不同的脱阴毛术语。42% 的病例在解剖描述中包含了对阴道口大小的描述,其中只有 38% 提供了公制测量值。这项研究发现,FGC 文件记录的质量差异很大。医疗服务提供者经常使用未指定的 FGC 代码、主观和/或看似不准确的 FGC/解剖描述,以及 FGC 和脱纤毛术的多个不同术语。显然,临床培训课程中需要开展更多的教育,以便:(1)识别 FGC 类型;(2)使用相应的 ICD 代码;(3)使用具体、客观的描述(包括存在/不存在结构和脱纤状态)。
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来源期刊
Journal of Immigrant and Minority Health
Journal of Immigrant and Minority Health PUBLIC, ENVIRONMENTAL & OCCUPATIONAL HEALTH-
CiteScore
3.70
自引率
5.30%
发文量
104
期刊介绍: Journal of Immigrant and Minority Health is an international forum for the publication of peer-reviewed original research pertaining to immigrant health from contributors in many diverse fields including public health, epidemiology, medicine and nursing, anthropology, sociology, population research, immigration law, and ethics. The journal also publishes review articles, short communications, letters to the editor, and notes from the field.
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