This section is designed to familiarize an organization with best practices, from The Joint Commission and other sources, for providing patients the opportunity to be identified as LGBTQ+ in health records, if they so wish. Adding LGBTQ+ self-identification options to an electronic health record system is a significant step a facility can take to help end LGBTQ+ health disparities with LGBTQ+ self-identification options in a facility's electronic health records.
There are 10 scored questions in this subsection. In order to receive the full 10 points in this subsection, a facility must have at least 6 or more of these best practices in place. Facilities with 3 to 5 of these best practices in place will receive a partial score of 5 for this subsection.
Scored best practices include:
Collecting information about sexual orientation and gender identity through the following:
Providing LGBTQ+ family inclusive health records with:
To receive credit your facility must:
Upload a screenshot or sample form showing how this information is captured. The EHR system must offer explicit fields for collecting this data, and cannot be simply in the free form notes.
To receive credit for collecting gender identity and sexual orientation data you will be required to provide a report showing what percentage of patients this data as well as race/ethnicity data has been collected for.
More information:
Documentation of both current gender identity and sex assigned at birth is critical for delivering appropriate care to transgender patients. Some transgender people may not identify as transgender, but only as male or female. In these cases, sex assigned at birth can indicate that the individual is transgender, which allows providers to offer the full range of care such as anatomically appropriate preventive screenings that meets the individual’s needs. Therefore, the current recommended best practice involves asking both sex assigned at birth and current gender identity. Current gender identity, name, and pronouns should be documented and used for communication with the patient, as well as things like name bands and room assignments.
To receive credit your facility must:
Upload a screenshot or sample form showing how this information is captured. The EHR system must offer explicit fields for collecting this data, and cannot be simply in the free form notes.
More information:
Examples:
To receive credit, a facility must:
Describe how this training is provided and upload supporting documentation (slides from training, employee handout, etc.). This training must address how to ask these questions in a respectful manner and how to record them within the hospital’s specific EHR. General LGBTQ+ trainings do not count.
More information:
A critical step in the process of effectively implementing SO/GI data collection in clinical settings is the training of staff on LGBTQ+ health disparities, and on how to use SO/GI data and manage it in ways that meet the clinical needs of LGBTQ+ patients while concurrently protecting confidentiality and privacy. Each facility will also need to train staff on how to collect and record SO/GI data within the facility’s electronic health records.
Examples:
To receive credit, a facility must:
Upload screenshot of a sample patient record display showing how the pronouns are displayed for healthcare staff to see.
More information:
Examples:
To receive credit, a facility must:
Upload screenshot of a sample patient record showing how the name in use is displayed.
More information:
Gathering patient gender identity and pronoun information is critical to providing affirming and inclusive care. Collecting a patient’s chosen name is also necessary in creating a safe healthcare environment for all patients.
The Fenway Institute’s guide, Ready, Set, Go!, offers tips and best practices on to collect patient data regarding sexual orientation and gender identity.
Examples:
To receive credit, a facility must:
Upload a screenshot or sample form showing how this information is explicitly captured
More information:
Check out this "Electronic Medical Records and the Transgender Patient: Recommendations from the World Professional Association for Transgender Health EMR Working Group" publication on how to capture a patient's organ inventory.
Examples:
To receive credit, a facility must:
Upload a screenshot or sample form showing how this information is captured. The EHR system must offer explicit fields for collecting this data, and cannot be simply in the free form notes.
To receive credit for collecting gender identity and sexual orientation data you will be required to provide a report showing what percentage of patients this data as well as race/ethnicity data has been collected for.
More information:
Examples:
To receive credit, a facility must:
Describe how this training is provided and upload supporting documentation (slides from training, employee handout, etc.). This training should be in addition to standard HIPAA training, or be in the form of a special section within HIPAA training that addresses the specific privacy needs of LGBTQ+ patients.
More information:
Transgender patients especially are often the victims of privacy breaches, where staff or providers might feel the need to “warn” the patient’s roommate about the patient’s transgender status, or invite other staff or providers to come see the patient. These privacy violations are not only unethical and illegal, but add to the high levels of discrimination transgender people already face in accessing healthcare, and discourage these patients from continuing or returning to seek care. For more information, see our page on HIPAA and LGBT Healthcare Equality.
Examples:
To receive credit, a facility must:
Upload a screenshot or sample form showing how this information is captured. The EHR system must offer explicit fields for collecting this data, and cannot be simply in the free form notes.
More information:
There are many kinds of family structures in our community today and hospital records should have ways to record these relationships. This is a practice that will help provide a welcoming environment for all patients.
This is important not only for same-sex parents, but for the realities of many families, where the traditional options of “mother” and “father” do not welcome a child raised by grandparents, a transgender parent, adoptive or foster parents, or other types of families. If you need information about the child’s legal guardian or birth parents, you can include separate questions for “birth parent” and “legal guardian,” with the option to duplicate answers from the parent/guardian section.
Examples:
To receive credit, your facility must:
Upload a screenshot or sample form showing how this information is captured. The EHR system must offer explicit fields for collecting this data, and cannot be simply in the free form notes.
More information:
There are many kinds of family structures in our community today and hospital records should have ways to record these relationships. Many facilities recognize unmarried partners with categories such as “life-partner,” “domestic partner” or “significant other.”
Here are some examples of facilities that allows patients to record their marital or relationship status in LGBTQ+ inclusive ways: