Obviously this would be very stupid of this person, but legitimate question (not trying to be inflammatory, honestly curious).
I sort of assumed a medical chart would explicitly include if someone was transgender/had transitioned, is that not the case? I guess the hysterectomy does that itself, but it feels like it would be something explicit to ensure the doctor doesn't overlook it when glancing at a chart? Because wouldn't that be potentially relevant to diagnosis/treatment? Obviously if you're like...there for a broken bone or at the dentist it's whatever, but if you were actually sick?
The answer is complicated. Electronic health record software applications do have a variety of ways that sex and gender can be indicated. These can even contradict each other on a single person’s record because data is entered from multiple sources. The information is often visible in different ways depending on what the user’s job role is in order to adhere to the HIPAA “minimum necessary rule”. The current gold standard is entering an “organ inventory” that can accurately capture the data of any variety of trans, nonbinary or intersex person’s anatomy, in combination with discreet data entry of legal sex, SAAB AND gender. However, the healthcare organization has to train its clinicians and registration staff to accurately and consistently capture that data. We aren’t there yet but we’re working on it. “We” being health information management and healthcare IT professionals.
Also, as others have said, many doctors do not read your chart. Signed, the person coordinating chart corrections and following up on patient amendment requests.
Organ inventory is a wild...you'd think it would be clear and then that would cause a doctor to then look at sections like organ inventory and scripts.
The data is used by both the clinical end users who are using and updating the record and by the electronic heath record system itself for decision support functionality such as warning users of contraindicated medications. It captures if someone has had a hysterectomy and if someone has both ovaries and testes, which happens. Unfortunately, IME, providers tend to assume there’s been a documentation error instead of recognizing that, yes, their patient is trans or intersex. This comic is accurate.
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u/SofishticatedGuppy Jul 31 '26
Obviously this would be very stupid of this person, but legitimate question (not trying to be inflammatory, honestly curious).
I sort of assumed a medical chart would explicitly include if someone was transgender/had transitioned, is that not the case? I guess the hysterectomy does that itself, but it feels like it would be something explicit to ensure the doctor doesn't overlook it when glancing at a chart? Because wouldn't that be potentially relevant to diagnosis/treatment? Obviously if you're like...there for a broken bone or at the dentist it's whatever, but if you were actually sick?