title: Documentation of Gender Identity in an Adolescent and Young Adult Clinic.
abstract: OBJECTIVE
  To determine if changing electronic health record (EHR) note templates can increase documentation of gender identity in an adolescent and young adult clinic.
  
  
  METHODS
  A two-step gender question was added to EHR note templates for physicals in February 2016. A retrospective chart review was performed 3 months before and after this addition. The primary measure was whether answers to the two-step question were documented. Gender identity/birth-assigned sex discordance, age, and use of the appropriate note template post-template change were also measured.
  
  
  RESULTS
  One hundred twenty-five pretemplate change and 106 post-template change physicals were reviewed with an inter-rater reliability of 97%. Documentation of answers to the two-step gender identity question increased from 11% to 84% (p < .001).
  
  
  CONCLUSIONS
  This study suggests that incorporating a standardized question into EHR note templates is effective at improving the documentation of gender identity in youth presenting for annual physicals.
authors.affiliation: Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, California. Electronic address: stanley.vance@ucsf.edu.
authors.forename: Stanley R
authors.initials: SR
authors.lastname: Vance
authors.affiliation: Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, California.
authors.forename: Veronika V
authors.initials: VV
authors.lastname: Mesheriakova
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D057286:Electronic Health Records / Q000706:statistics & numerical data*; D005260:Female; D005783:Gender Identity; D006801:Humans; D008297:Male; D015203:Reproducibility of Results; D012189:Retrospective Studies; D063106:Transgender Persons / Q000706:statistics & numerical data*; D055815:Young Adult
keywords: Gender identity; Health services for transgender persons; Transgender persons