SHM Converge Scientific Abstract ePoster Gallery-Improving Confidential Care: Utilizing Electronic Health Record Modifications to Increase Use of Adolescent Sensitive Notes

Improving Confidential Care: Utilizing Electronic Health Record Modifications to Increase Use of Adolescent Sensitive Notes

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This quality improvement project aimed to protect adolescent confidentiality in pediatric hospital medicine notes by increasing use of adolescent sensitive notes (ASN), which are not visible to guardians, while reducing documentation of sexual history and substance use in standard history and physical (H&P) notes that are visible under the 21st Century Cures Act.<br /><br />The intervention focused on PHM patients ages 13–17 from 8/1/20 to 5/31/21, excluding patients with developmental delay or altered mental status. Three changes were introduced:  <br />1. Disappearing help text was added to the PHM H&P template to remind clinicians to use ASN appropriately.  <br />2. The help text was later revised to encourage copying the two social history domains into ASN.  <br />3. Education about the 21st Century Cures Act and ASN use was provided to residents and PHM advanced practice providers.<br /><br />The project found that this simple electronic health record modification was associated with increased ASN use and decreased documentation of sexual history and substance use in H&P notes. A balancing measure showed that unapproved content in ASN decreased from 90.7% to 54.9%, suggesting improved appropriateness of sensitive documentation. ASN use was not associated with sex, insurance, race, ethnicity, or whether the author was an APP versus a resident.<br /><br />Overall, the intervention helped maintain adolescent confidentiality. The authors suggest that disappearing help text could be expanded to other specialties and adapted to prompt appropriate documentation in other clinical situations.

Asset Subtitle

Kaitlyn Skrzypcak

Meta Tag

Author List Kaitlyn Skrzypcak, Sarah Bauer, Vanessa McFadden

Category Research

Concept Confidentiality

Concept Adolescent-Sensitive Notes

Concept Electronic Health Record

Concept 21st Century Cures Act

Concept History and Physical Note

Distinguished Non-Finalist

Presenter Organization Medical College of Wisconsin Affiliated Hospitals

Presenting Author Kaitlyn Skrzypcak

Track Quality Improvement

Keywords

adolescent confidentiality

pediatric hospital medicine

adolescent sensitive notes

21st Century Cures Act

electronic health record

sexual history

substance use

documentation quality improvement

help text intervention

health information privacy

Confidentiality

Adolescent-Sensitive Notes

Electronic Health Record

21st Century Cures Act

History and Physical Note