Patient, Resident Physician, and Visit Factors Associated with Documentation of Sexual History in the Outpatient Setting

This study examines the inclusion of sexual history in health care maintenance visits at two urban university outpatient clinics. While an accurate sexual history is an important component to patient health management, little is known about whether sexual histories are systematically undertaken in an outpatient setting.

The authors conducted a cross-sectional chart review of 260 medical charts created by 26 internal medicine residents from February through August 2007. The authors analyzed the charts for mention of elements of sexual history, including current and past sexual activity, number of sexual partners, gender of sexual partners, and history of sexually transmitted infections.

Key Findings:

  • Only one quarter of charts recorded any element of sexual history.
  • Sexual history documentation was associated with younger age, patient concern about a sexually transmitted infection, birth control use, and genitourinary and abdominal complaints.
  • Low rates of sexual history documentation were observed with older patients and patients without a specified marital status.

This research indicates that the majority of patients receiving routine outpatient care in two university outpatient clinics did not have adequate documentation of their sexual history.