Chart Review Elements for Adherence to Recommendations for Care and Criteria to Meet Recommendations
| Element Reviewed | Criteria to Satisfy Recommendation | Action Taken If Criteria Not Met |
|---|---|---|
| Name/gender markers | Accurate gender identity, name, and/or pronouns documented | Patient identifiers updated in chart |
| Appropriate prescription for PrEP | Documentation of PrEP prescription for anyone who met the following criteria: AMAB who have sex with AMAB are sexually active and have 1 of the following: an HIV-infected partner; recent syphilis, gonorrhea, or chlamydia infection; or inconsistent condom use during anal sex Sexually active people who have 1 of the following: a serodiscordant sex partner, inconsistent condom use during sex with a high-risk partner of unknown HIV status, or recent syphilis or gonorrhea infection IVDU with sharing of injection paraphernalia or engagement in risky sexual activity | Message sent to provider notifying them of the action needed |
| Contraception/family planning | Documentation of discussion regarding need for contraception/family planning | |
| Mental health | Documentation of depression screening (PHQ-2 and PHQ-9) within the past year and/or discussion regarding therapy or counseling | |
| Health maintenance | Papanicolaou smear per USPSTF recommendations, if the patient has a cervix Mammograms starting at age 50, per USPSTF recommendations, if patient has breast tissue Osteoporosis screening for transmasculine transgender patients at age 50 on testosterone for >10 years; otherwise starting at age 60 | |
| Follow-up | Appointment scheduled with primary care provider | |
| Gender-affirming hormone therapy | ||
| Testosterone | Absence of absolute contraindications (ESRD, acute hepatitis, pregnancy, unstable CAD, hematocrit > 55%, and active sex hormone–sensitive cancer) Relative contraindications documented and addressed (HTN, T2DM, chronic liver disease, personal or family history of CAD, PCOS, VTE, and history of sex hormone–sensitive cancer) Documentation of laboratory tests at appropriate intervals (total testosterone at 3, 6, and 12 months in year 1, then annually if stable; H/H at baseline and at 3, 6, and 12 months in year 1, then annually if stable) | Message sent to provider notifying them of the action needed |
| Spironolactone | Absence of contraindications (hyperkalemia, renal insufficiency)Documentation of laboratory tests at appropriate intervals (BMP at baseline, 2 to 4 weeks, 3 months, 6 months, and 12 months, then annually) | |
| Estrogen | Absence of absolute contraindications (ESRD, acute hepatitis, personal history of estrogen-sensitive cancer, and history of VTE with ongoing smoking) Relative contraindication documented and addressed (HTN, T2DM, chronic liver disease, smoking, migraine with aura, age > 40, obesity, CAD, personal history of VTE, and prolactinoma) Documentation of laboratory tests at appropriate intervals (estradiol at 3 and 6 months, then as needed; total testosterone at 3, 6, and 12 months, then as needed) | |
Abbreviations: AMAB, assigned male at birth; BMP, basic metabolic panel; CAD, coronary artery disease; ESRD, end-stage renal disease; H/H, hemoglobin/hematocrit; HTN, hypertension; IVDU, intravenous drug user; PCOS, polycystic ovary syndrome; PHQ, patient health questionnaire; PrEP, pre-exposure prophylaxis; T2DM, type 2 diabetes mellitus; USPSTF, United States Preventive Services Task Force; VTE, venous thromboembolism.