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

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 conduc...

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Podrobná bibliografia
Vydané v:	Journal of immigrant and minority health Ročník 26; číslo 4; s. 667 - 673
Hlavní autori:	Creger, Jae, Abdikeir, Kalthum, Kaczmarczik, Kyra, Chaisson, Nicole, Johnson-Agbakwu, Crista E., Robinson, Beatrice “Bean” E., Connor, Jennifer Jo
Médium:	Journal Article
Jazyk:	English
Vydavateľské údaje:	New York Springer US 01.08.2024 Springer Nature B.V
Predmet:	Anatomy Chart reviews Circumcision Clinical training Clinics Comparative Law Cutting demographic statistics Demography Descriptions descriptive statistics Documentation education Educational programs Electronic health records Electronic medical records Female circumcision female genitalia Females Health Health records Health services Hospitals International & Foreign Law Measurement Medical records Medicine Medicine & Public Health Minnesota Nomenclature Original Paper pain Patients Private International Law Public Health Quality of care Sociology Statistics Subjectivity telemedicine Terminology Minnesota Sexual pain Female genital cutting ICD coding Medical documentation
ISSN:	1557-1912, 1557-1920, 1557-1920
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Popis
Shrnutí:	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).
Bibliografia:	ObjectType-Article-1 SourceType-Scholarly Journals-1 ObjectType-Feature-2 content type line 14 content type line 23
ISSN:	1557-1912 1557-1920 1557-1920
DOI:	10.1007/s10903-024-01595-5