Abuse disclosure and documentation in the medical record: an observational matched-cohort study in the US Military Health System

Aim This study aims to evaluate the overall incidence of abuse code documentation in the medical records of patients assigned female, and the relationships between abuse code documentation and patient characteristics, healthcare utilization (e.g., overall visits, emergency room visits, opioid prescription receipts), and diagnoses received in the year following documentation.Subject and methods Records of patients assigned female in the medical record were evaluated in this observational, retrospective study, which received a non-research determination by the Brooke Army Medical Center Institutional Review Board (C.2019.156n). Patient cohorts included those who received an initial healthcare encounter (i.e., index visit) in which physical, sexual, or psychological abuse was documented and those who never received documentation corresponding to abuse during the study period.Results The probability of abuse code documentation varied across patient characteristics and medical information. Using 1:1 propensity score matching, patients who received abuse code documentation had higher post-index healthcare utilization overall, as well as increased odds of an emergency visit, receipt of a mental health diagnosis, and receipt of an opioid prescription within a year of the index date.Conclusion These findings highlight the need for system-level interventions to ensure standardized screening and care pathways for those who experience abuse. Such programs could mitigate barriers to patient disclosure of abuse and support patient-centered policies.