Description
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.
Learning Objective: To describe variations in the documentation of sexual trauma histories in clinical notes.
Authors:
Audrey Jones (Presenter)
VA Salt Lake City Health Care System
Warren Pettey, VA Salt Lake City Health Care System
Marjorie Carter, VA Salt Lake City Health Care System
Emily Brignone, VA Salt Lake City Health Care System
Andrew Redd, VA Salt Lake City Health Care System
Ying Suo, VA Salt Lake City Health Care System
Guy Divita, VA Salt Lake City Health Care System
Rebecca Blais, VA Salt Lake City Health Care System
Jamison Fargo, VA Salt Lake City Health Care System
Adi Gundlapalli, VA Salt Lake City Health Care System
Presentation Materials: