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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Veröffentlicht in:	Journal of immigrant and minority health Jg. 26; H. 4; S. 667 - 673
Hauptverfasser:	Creger, Jae, Abdikeir, Kalthum, Kaczmarczik, Kyra, Chaisson, Nicole, Johnson-Agbakwu, Crista E., Robinson, Beatrice “Bean” E., Connor, Jennifer Jo
Format:	Journal Article
Sprache:	Englisch
Veröffentlicht:	New York Springer US 01.08.2024 Springer Nature B.V
Schlagworte:	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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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).
AbstractList	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). 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).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).
Author	Johnson-Agbakwu, Crista E. Kaczmarczik, Kyra Chaisson, Nicole Creger, Jae Abdikeir, Kalthum Robinson, Beatrice “Bean” E. Connor, Jennifer Jo
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Cites_doi	10.3390/healthcare11050702 10.1177/003335491613100218 10.1186/s12889-021-11160-6 10.1016/j.ijgo.2015.04.033 10.3917/popu.1602.0224 10.1186/s12889-020-09151-0 10.1186/s12889-022-14773-7 10.1038/s41443-020-0302-0 10.1111/1471-0528.16086 10.1007/s10903-020-01018-1 10.3109/01443615.2014.960826 10.1016/j.jbi.2008.08.010 10.1007/s10903-018-0833-3 10.1542/peds.2020-1012 10.1080/01443610601124257
ContentType	Journal Article
Copyright	The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2024. Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law. 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.
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References	EarpBDJohnsdotterSCurrent critiques of the WHO policy on female genital mutilationInt J Impot Res202133219620910.1038/s41443-020-0302-032457498 LevyATBeausangJKFinleyEDWolfSMProvider knowledge and attitudes about female genital mutilation/cutting in PhiladelphiaJ Immigr Minor Health202123455310.1007/s10903-020-01018-132405719 SuricoDAmadoriRGastaldoLBTinelliRSuricoNFemale genital cutting: a survey among healthcare professionals in ItalyJ Obstet Gynaecol201535439361:STN:280:DC%2BC2M7ltlehtA%3D%3D10.3109/01443615.2014.96082625265525 LaneJLJohnson-AgbakwuCEWarrenNBudhathokiCColeECFemale genital cutting: clinical knowledge, attitudes, and practices from a provider survey in the USJ Immigr Minor Health2019219546410.1007/s10903-018-0833-330443876 DawsonAHomerCSTurkmaniSBlackKVarolNA systematic review of doctors’ experiences and needs to support the care of women with female genital mutilationInt J Gynaecol Obstet20151311354010.1016/j.ijgo.2015.04.03326118329 PersuCChappleCRCauniVGutueSGeavletePPelvic organ prolapse quantification system (POP–Q) - a new era in pelvic prolapse stagingJ Med Life20114175811:STN:280:DC%2BC3MvkvFejug%3D%3D215055773056425 YoungJNourNMMacauleyRCDiagnosis, management, and treatment of female genital mutilation or cutting in girlsPediatrics20201462e2020101210.1542/peds.2020-101232719089 Cottler-CasanovaSHorowiczMGieszlSJohnson‐AgbakwuCAbdulcadirJCoding female genital mutilation/cutting and its complications using the International classification of diseases: a commentaryBJOG2020127666041:STN:280:DC%2BB3MbpsVWltA%3D%3D10.1111/1471-0528.1608631930648 KawousRvan den MuijsenberghMETCGeraciDHendriksKRMOrtensiLEHilverdaFBurdorfAEstimates of female genital mutilation/cutting in the Netherlands: a comparison between a nationwide survey in midwifery practices and extrapolation-modelBMC Public Health2020201103310.1186/s12889-020-09151-0326003807325136 World Health Organization, World Health Organization. Eliminating female genital mutilation: an interagency statement-OHCHR, UNAIDS, UNDP, UNECA. 2008. https://www.who.int/publications/i/item/9789241596442. World Health Organization. Understanding and addressing violence against women: female genital mutilation. World Health Organ. 2012. https://www.who.int/publications/i/item/WHO-RHR-12.41. Cottler-CasanovaSHorowiczMGayet-AgeronAAbdulcadirJFemale genital mutilation/cutting (FGM/C) coding capacities in Swiss university hospitals using the International classification of diseases (ICD)BMC Public Health202121111511:STN:280:DC%2BB2c7ovFWktw%3D%3D10.1186/s12889-021-11160-6341346888207741 TaumbergerNGruberTEdlerKTrutnovskyGBracicTSemrlNSchützAMEisneckerKTamussinoKFluhrHFemale genital mutilation/cutting incidence, diagnostic capacities, and obstetric outcomes among migrant women: a single-center retrospective analysis in a 10-year birth cohort in AustriaBMC Public Health2023231681:STN:280:DC%2BB28nnslSmtw%3D%3D10.1186/s12889-022-14773-7366276189832771 OgunsijiOOgbeideAEUssherJExperiences of primary healthcare workers in Australia towards women and girls living with female genital mutilation/cutting (FGM/C): a qualitative studyHealthc (Basel)202311570210.3390/healthcare11050702PMID: 36900707; PMCID: PMC10001128 AndroALesclingandMGrieveMReevePFemale genital mutilation. Overview and current knowledgePopulation20167122179610.3917/popu.1602.0224 GoldbergHStuppPOkorohEBeseraGGoodmanDDanelIFemale genital mutilation/cutting in the United States: updated estimates of women and girls at risk, 2012Public Health Rep20161312340710.1177/003335491613100218269576694765983 HarrisPATaylorRThielkeRPayneJGonzalezNCondeJGResearch electronic data capture (REDCap)—A metadata-driven methodology and workflow process for providing translational research informatics supportJ Biomed Inf20094223778110.1016/j.jbi.2008.08.010 ZaidiNKhalilARobertsCBrowneMKnowledge of female genital mutilation among healthcare professionalsJ Obstet Gynaecol200727216141:STN:280:DC%2BD2s3ksFaisw%3D%3D10.1080/0144361060112425717454465 BD Earp (1595_CR5) 2021; 33 AT Levy (1595_CR6) 2021; 23 J Young (1595_CR16) 2020; 146 A Andro (1595_CR2) 2016; 71 N Taumberger (1595_CR13) 2023; 23 R Kawous (1595_CR15) 2020; 20 JL Lane (1595_CR7) 2019; 21 N Zaidi (1595_CR9) 2007; 27 S Cottler-Casanova (1595_CR14) 2021; 21 PA Harris (1595_CR17) 2009; 42 D Surico (1595_CR8) 2015; 35 C Persu (1595_CR18) 2011; 4 O Ogunsiji (1595_CR11) 2023; 11 H Goldberg (1595_CR3) 2016; 131 1595_CR4 1595_CR1 S Cottler-Casanova (1595_CR12) 2020; 127 A Dawson (1595_CR10) 2015; 131
References_xml	– reference: LevyATBeausangJKFinleyEDWolfSMProvider knowledge and attitudes about female genital mutilation/cutting in PhiladelphiaJ Immigr Minor Health202123455310.1007/s10903-020-01018-132405719 – reference: AndroALesclingandMGrieveMReevePFemale genital mutilation. Overview and current knowledgePopulation20167122179610.3917/popu.1602.0224 – reference: YoungJNourNMMacauleyRCDiagnosis, management, and treatment of female genital mutilation or cutting in girlsPediatrics20201462e2020101210.1542/peds.2020-101232719089 – reference: TaumbergerNGruberTEdlerKTrutnovskyGBracicTSemrlNSchützAMEisneckerKTamussinoKFluhrHFemale genital mutilation/cutting incidence, diagnostic capacities, and obstetric outcomes among migrant women: a single-center retrospective analysis in a 10-year birth cohort in AustriaBMC Public Health2023231681:STN:280:DC%2BB28nnslSmtw%3D%3D10.1186/s12889-022-14773-7366276189832771 – reference: OgunsijiOOgbeideAEUssherJExperiences of primary healthcare workers in Australia towards women and girls living with female genital mutilation/cutting (FGM/C): a qualitative studyHealthc (Basel)202311570210.3390/healthcare11050702PMID: 36900707; PMCID: PMC10001128 – reference: LaneJLJohnson-AgbakwuCEWarrenNBudhathokiCColeECFemale genital cutting: clinical knowledge, attitudes, and practices from a provider survey in the USJ Immigr Minor Health2019219546410.1007/s10903-018-0833-330443876 – reference: ZaidiNKhalilARobertsCBrowneMKnowledge of female genital mutilation among healthcare professionalsJ Obstet Gynaecol200727216141:STN:280:DC%2BD2s3ksFaisw%3D%3D10.1080/0144361060112425717454465 – reference: EarpBDJohnsdotterSCurrent critiques of the WHO policy on female genital mutilationInt J Impot Res202133219620910.1038/s41443-020-0302-032457498 – reference: Cottler-CasanovaSHorowiczMGayet-AgeronAAbdulcadirJFemale genital mutilation/cutting (FGM/C) coding capacities in Swiss university hospitals using the International classification of diseases (ICD)BMC Public Health202121111511:STN:280:DC%2BB2c7ovFWktw%3D%3D10.1186/s12889-021-11160-6341346888207741 – reference: DawsonAHomerCSTurkmaniSBlackKVarolNA systematic review of doctors’ experiences and needs to support the care of women with female genital mutilationInt J Gynaecol Obstet20151311354010.1016/j.ijgo.2015.04.03326118329 – reference: Cottler-CasanovaSHorowiczMGieszlSJohnson‐AgbakwuCAbdulcadirJCoding female genital mutilation/cutting and its complications using the International classification of diseases: a commentaryBJOG2020127666041:STN:280:DC%2BB3MbpsVWltA%3D%3D10.1111/1471-0528.1608631930648 – reference: PersuCChappleCRCauniVGutueSGeavletePPelvic organ prolapse quantification system (POP–Q) - a new era in pelvic prolapse stagingJ Med Life20114175811:STN:280:DC%2BC3MvkvFejug%3D%3D215055773056425 – reference: GoldbergHStuppPOkorohEBeseraGGoodmanDDanelIFemale genital mutilation/cutting in the United States: updated estimates of women and girls at risk, 2012Public Health Rep20161312340710.1177/003335491613100218269576694765983 – reference: KawousRvan den MuijsenberghMETCGeraciDHendriksKRMOrtensiLEHilverdaFBurdorfAEstimates of female genital mutilation/cutting in the Netherlands: a comparison between a nationwide survey in midwifery practices and extrapolation-modelBMC Public Health2020201103310.1186/s12889-020-09151-0326003807325136 – reference: World Health Organization. Understanding and addressing violence against women: female genital mutilation. World Health Organ. 2012. https://www.who.int/publications/i/item/WHO-RHR-12.41. – reference: SuricoDAmadoriRGastaldoLBTinelliRSuricoNFemale genital cutting: a survey among healthcare professionals in ItalyJ Obstet Gynaecol201535439361:STN:280:DC%2BC2M7ltlehtA%3D%3D10.3109/01443615.2014.96082625265525 – reference: HarrisPATaylorRThielkeRPayneJGonzalezNCondeJGResearch electronic data capture (REDCap)—A metadata-driven methodology and workflow process for providing translational research informatics supportJ Biomed Inf20094223778110.1016/j.jbi.2008.08.010 – reference: World Health Organization, World Health Organization. Eliminating female genital mutilation: an interagency statement-OHCHR, UNAIDS, UNDP, UNECA. 2008. https://www.who.int/publications/i/item/9789241596442. – volume: 11 start-page: 702 issue: 5 year: 2023 ident: 1595_CR11 publication-title: Healthc (Basel) doi: 10.3390/healthcare11050702 – volume: 131 start-page: 340 issue: 2 year: 2016 ident: 1595_CR3 publication-title: Public Health Rep doi: 10.1177/003335491613100218 – volume: 21 start-page: 1151 issue: 1 year: 2021 ident: 1595_CR14 publication-title: BMC Public Health doi: 10.1186/s12889-021-11160-6 – volume: 131 start-page: 35 issue: 1 year: 2015 ident: 1595_CR10 publication-title: Int J Gynaecol Obstet doi: 10.1016/j.ijgo.2015.04.033 – volume: 71 start-page: 217 issue: 2 year: 2016 ident: 1595_CR2 publication-title: Population doi: 10.3917/popu.1602.0224 – ident: 1595_CR4 – volume: 20 start-page: 1033 issue: 1 year: 2020 ident: 1595_CR15 publication-title: BMC Public Health doi: 10.1186/s12889-020-09151-0 – volume: 23 start-page: 68 issue: 1 year: 2023 ident: 1595_CR13 publication-title: BMC Public Health doi: 10.1186/s12889-022-14773-7 – volume: 33 start-page: 196 issue: 2 year: 2021 ident: 1595_CR5 publication-title: Int J Impot Res doi: 10.1038/s41443-020-0302-0 – volume: 127 start-page: 660 issue: 6 year: 2020 ident: 1595_CR12 publication-title: BJOG doi: 10.1111/1471-0528.16086 – volume: 23 start-page: 45 year: 2021 ident: 1595_CR6 publication-title: J Immigr Minor Health doi: 10.1007/s10903-020-01018-1 – ident: 1595_CR1 – volume: 4 start-page: 75 issue: 1 year: 2011 ident: 1595_CR18 publication-title: J Med Life – volume: 35 start-page: 393 issue: 4 year: 2015 ident: 1595_CR8 publication-title: J Obstet Gynaecol doi: 10.3109/01443615.2014.960826 – volume: 42 start-page: 377 issue: 2 year: 2009 ident: 1595_CR17 publication-title: J Biomed Inf doi: 10.1016/j.jbi.2008.08.010 – volume: 21 start-page: 954 year: 2019 ident: 1595_CR7 publication-title: J Immigr Minor Health doi: 10.1007/s10903-018-0833-3 – volume: 146 start-page: e20201012 issue: 2 year: 2020 ident: 1595_CR16 publication-title: Pediatrics doi: 10.1542/peds.2020-1012 – volume: 27 start-page: 161 issue: 2 year: 2007 ident: 1595_CR9 publication-title: J Obstet Gynaecol doi: 10.1080/01443610601124257
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Snippet	To evaluate the quality of Electronic Health Record (EHR) documentation practices of Female Genital Cutting (FGC) by medical providers. A retrospective chart...
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SubjectTerms	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
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Title	The Need for Standardized Nomenclature in Electronic Documentation of Female Genital Cutting in Health Records
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