Documentation of Sexual and Menstrual Histories for Adolescent Patients in the Inpatient Setting

Abstract

Study objective: 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.

Results: 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).

Conclusion: 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.

Keywords: Adolescent; Gynecology; Menstruation; Quality indicators.