title: Patient, resident physician, and visit factors associated with documentation of sexual history in the outpatient setting.
abstract: BACKGROUND
  Providers need an accurate sexual history for appropriate screening and counseling, but data on the patient, visit, and physician factors associated with sexual history-taking are limited.
  
  
  OBJECTIVE
  To assess patient, resident physician, and visit factors associated with documentation of a sexual history at health care maintenance (HCM) visits.
  
  
  METHODS
  Retrospective cross-sectional chart review.
  
  
  METHODS
  Review of all HCM clinic notes (n = 360) by 26 internal medicine residents from February to August of 2007 at two university-based outpatient clinics.
  
  
  METHODS
  Documentation of sexual history and patient, resident, and visit factors were abstracted using structured tools. We employed a generalized estimating equations method to control for correlation between patients within residents. We performed multivariate analysis of the factors significantly associated with the outcome of documentation of at least one component of a sexual history.
  
  
  RESULTS
  Among 360 charts reviewed, 25% documented at least one component of a sexual history with a mean percent by resident of 23% (SD = 18%). Factors positively associated with documentation were: concern about sexually transmitted infection (referent: no concern; OR = 4.2 [95% CI = 1.3-13.2]); genitourinary or abdominal complaint (referent: no complaint; OR = 4.3 [2.2-8.5]); performance of other HCM (referent: no HCM performed; OR = 3.2 [1.5-7.0]), and birth control use (referent: no birth control; OR = 3.0 [1.1, 7.8]). Factors negatively associated with documentation were: age groups 46-55, 56-65, and >65 (referent: 18-25; ORs = 0.1, 0.1, and 0.2 [0.0-0.6, 0.0-0.4, and 0.1-0.6]), and no specified marital status (referent: married; OR = 0.5 [0.3-0.8]).
  
  
  CONCLUSIONS
  Our findings highlight the need for an emphasis on documentation of a sexual history by internal medicine residents during routine HCM visits, especially in older and asymptomatic patients, to ensure adequate screening and counseling.
authors.affiliation: Department of Medicine, University of Colorado, Aurora, CO, USA. Danielle.loeb@ucdenver.edu
authors.forename: Danielle F
authors.initials: DF
authors.lastname: Loeb
authors.forename: Rita S
authors.initials: RS
authors.lastname: Lee
authors.forename: Ingrid A
authors.initials: IA
authors.lastname: Binswanger
authors.forename: Misoo C
authors.initials: MC
authors.lastname: Ellison
authors.forename: Eva M
authors.initials: EM
authors.lastname: Aagaard
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000553:Ambulatory Care / Q000379:methods* / Q000523:psychology; D003430:Cross-Sectional Studies; D004282:Documentation / Q000379:methods*; D005260:Female; D006801:Humans; D007396:Internship and Residency / Q000379:methods*; D008297:Male; D008487:Medical History Taking / Q000379:methods*; D008875:Middle Aged; D010817:Physician-Patient Relations; D010820:Physicians; D012189:Retrospective Studies; D012725:Sexual Behavior / Q000523:psychology; D012749:Sexually Transmitted Diseases / Q000175:diagnosis / Q000517:prevention & control / Q000523:psychology; D055815:Young Adult