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青春期女孩年度健康体检时的月经史采集

Menstrual History-Taking at Annual Well Visits for Adolescent Girls.

作者信息

McShane Mark, Perucho James, Olsakowski Melissa, Gaughan John P, Brown Robert T, Feldman-Winter Lori

机构信息

Cooper Medical School of Rowan University, Camden, New Jersey.

Cooper Medical School of Rowan University, Camden, New Jersey.

出版信息

J Pediatr Adolesc Gynecol. 2018 Dec;31(6):566-570. doi: 10.1016/j.jpag.2018.07.012. Epub 2018 Aug 3.

DOI:10.1016/j.jpag.2018.07.012
PMID:30081084
Abstract

STUDY OBJECTIVE

To determine the rates at which primary care providers elicit menstrual histories from adolescent girls at well visits.

DESIGN

Retrospective chart review.

SETTING

The departments of Pediatrics, Adolescent Medicine, and Family Medicine of Cooper University Healthcare from January 1, 2010 to June 1, 2016.

PARTICIPANTS

Women aged 12-21 years who were seen for a well visit in the described setting.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

We searched physician well visit notes for documentation of the following aspects of menstrual history: menarche, last menstrual period, usual length of cycle, and the presence or absence of associated symptoms (such as pain and cramps). The presence or absence of each aspect was recorded in a binary fashion in a deidentified data set.

RESULTS

A total of 954 unique charts were analyzed: 415 from Adolescent Medicine, 289 from Family Medicine, and 250 from General Pediatrics at Cooper University Healthcare. Adolescent Medicine was 6.44 times more likely to take a complete menstrual history than Family Medicine (P < .0001) and 5.80 times more likely than Pediatrics (P < .0001). There was no statistical difference between Pediatrics and Family Medicine (odds ratio, 0.55; P = .3150).

CONCLUSION

Menstrual history-taking is often incomplete and can vary between departments, even within the same institution. These results indicate opportunities to raise awareness about the importance of a complete menstrual history and to develop quality improvement initiatives to increase documentation of the complete menstrual history.

摘要

研究目的

确定基层医疗服务提供者在青少年女孩健康检查时询问月经史的比例。

设计

回顾性病历审查。

地点

2010年1月1日至2016年6月1日期间库珀大学医疗保健中心的儿科、青少年医学科和家庭医学科。

参与者

在上述地点接受健康检查的12至21岁女性。

干预措施

无。

主要观察指标

我们在医生的健康检查记录中查找月经史以下方面的记录:初潮、末次月经、月经周期的通常长度以及是否存在相关症状(如疼痛和痉挛)。每个方面的有无情况以二元方式记录在一个去识别化的数据集中。

结果

共分析了954份独立病历:库珀大学医疗保健中心的青少年医学科415份、家庭医学科289份、普通儿科250份。青少年医学科获取完整月经史的可能性是家庭医学科的6.44倍(P <.0001),是儿科的5.80倍(P <.0001)。儿科和家庭医学科之间无统计学差异(优势比为0.55;P = 0.3150)。

结论

月经史询问往往不完整,且不同科室之间存在差异,即使在同一机构内也是如此。这些结果表明有机会提高对完整月经史重要性的认识,并制定质量改进措施以增加完整月经史的记录。

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