Patient, resident physician, and visit factors associated with documentation of sexual history in the outpatient setting.

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.

Objectives: To assess patient, resident physician, and visit factors associated with documentation of a sexual history at health care maintenance (HCM) visits.

Design: Retrospective cross-sectional chart review.

Participants: 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.

Measurements: 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.

Key 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.