Documentation Practices for Transgender Youth Admitted to an Inpatient Psychiatric Unit

Background: Population-based surveys estimate that 0.7% of youth (13 to 17 y of age) in the United States identifies as transgender. Transgender youth are at an increased risk of anxiety, depression, and suicide attempts that often require inpatient care. Unfortunately, because of perceived insensitivity to gender identity from their providers, which includes incorrect use of names and/or pronouns, they may delay seeking necessary care. To date, there have been no specific documentation practice guidelines published by the International Association of Child and Adolescent Psychiatry and Allied Professions, American Academy of Child and Adolescent Psychiatry (AACAP), or other professional associations. The main goal of this study was to review documentation practices among multidisciplinary teams caring for hospitalized transgender youth on a child and adolescent inpatient psychiatry unit. Methods: Retrospective chart reviews were completed for 44 transgender patients who were hospitalized between 2008 and 2017. The charts were reviewed for consistency in the documentation of name and gender by the multidisciplinary team. Members included child and adolescent staff psychiatrists, residents, fellows, nurses, nurse practitioners, physician assistants, and social workers. Inconsistency was defined as at least 2 members of the team referring to a patient by a different name and/or gender pronoun in separate notes or >2 interchanges of name and/or gender pronoun in a single note. Kappa coefficient was calculated between each team member role to estimate exact agreement statistics. Results: In 43.2% (n=19) of cases, team members did not have a consistent approach to documenting a patient's name and/or gender pronoun and 18% (n=8) of discharge summaries were also inconsistent in this documentation. The greatest agreement in documentation practices was noted between the team and the staff psychiatrist (kappa=0.446). Conclusions: Findings from this study suggest that inpatient treatment teams show inconsistency in documentation practices for youth transgender inpatients. Further work is necessary to understand the implications of these findings for patient satisfaction and clinical outcomes.