January 17, 2025

If the patient’s sex assigned at birth is Male and there is no documentation of that person identifying otherwise, would we choose Gender as “Man” or “Non-Disclosed” Or UNK since it wasn’t asked?

With no documentation for gender, use unknown. Non-disclosed is reserved for the patient actually declining to answer, meaning I would expect to see documentation that they declined to answer. I would also not assume and go with the same as sex. It is better to show that not everyone is collecting this, rather than fill in (potentially incorrectly).

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