Regional Variations in Documentation of Sexual Trauma Concepts in Electronic Medical Records in the United States Veterans Health Administration

Audrey L. Jones, Warren B.P. Pettey, Marjorie E. Carter, Emily Brignone, Andrew Redd, Ying Suo, Guy Divita, Rebecca K. Blais, Jamison D. Fargo, Adi V. Gundlapalli

Research output: Contribution to journalArticlepeer-review

1 Scopus citations

Abstract

Background: Experiences of sexual trauma are associated with adverse patient and health system outcomes, but are not systematically documented in electronic health records (EHR). Objective: To describe variations in how sexual trauma is documented in the Veterans Health Adminstration's EHR. Methods: Sexual trauma concepts were extracted from from 362,559 clinical notes using a natural language processing pipeline. Results: We observed variations in the presence of sexual trauma in notes across five United States regions: Pacific, Continental, Midwest, North Atlantic, Southeast. We also observed variations in the types of notes used to document sexual trauma (e.g., mental health, primary care) and sources of sexual trauma (e.g., adult, childhood, military) mentioned in the EHR. Our findings illustrate potential differences in cultural norms related to patient disclosure of sensitive information, and provider documentation. Standardized protocol for eliciting and documenting sexual trauma histories are needed to ensure Veteran access to high quality, trauma-informed care.

Original languageEnglish (US)
Pages (from-to)514-522
Number of pages9
JournalAMIA ... Annual Symposium proceedings. AMIA Symposium
Volume2019
StatePublished - 2019
Externally publishedYes

ASJC Scopus subject areas

  • Medicine(all)

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