Education in Neurology Resident Documentation Using Payroll Simulation

Medical record-keeping educational interventions for medical students and residents: a systematic review

BACKGROUND

Medical records, encompassing patient histories, progress notes, and more, play a crucial role in patient care and treatment, healthcare communication, medico-legal matters, and supporting financial documentation.

OBJECTIVE

Despite their significance, literature suggests inconsistencies in record quality and insufficient formal medical record-keeping education for medical students and residents. The study aimed to identify and evaluate the effectiveness of educational interventions by conducting a systematic review.

METHOD

A literature search covering 2003-2023 and review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was undertaken.

RESULTS

The literature search identified 44 relevant studies for inclusion. Educational methods, including lectures, feedback, workshops and discussions, addressed different components of the clinical record. The review revealed positive impacts on participant satisfaction, skills and attitudes related to record-keeping. However, some studies reported no significant positive outcomes, emphasising the need for higher-level evidence. Most studies adopted a single-group pretest-posttest design, presenting challenges in control group implementation. The Kirkpatrick evaluation levels were primarily at level 2, with few studies reaching level 3. The absence of studies at level 4 suggested the need for more robust evidence. Studies targeted medical residents more frequently than medical students, with a lack of interventions during the first year of medical education.

CONCLUSION

Despite limitations including language bias and methodological variations, the review revealed diverse educational strategies and highlighted the necessity for more randomised controlled trials and studies providing higher-level evidence to enhance clinical record-keeping skills among medical students and residents.

IMPLICATIONS

Medical record-keeping educational interventions can significantly improve the documentation skills of medical students and residents, thereby enhancing patient care, communication and medico-legal compliance.

Lost in translation: Unveiling medical students' untold errors of medical history documentation

OBJECTIVE

The accurate documentation of a medical history interview is an important goal in medical education. As students' documentation of medical history interviews is mostly decentralised on the wards, a systematic assessment of documentation quality is missing. We therefore evaluated the extent of details missed in students' medical history reports in a standardised setting.

METHODS

In this prospective, observational study, 123 of 380 students (32.4%) participated in an Objective Structured Clinical Examination (OSCE) regarding history taking and documentation. Based on the interviews and nine deductively selected main categories, a categorical system was established using a summarising qualitative content analysis. The items in the transcripts (defined as ground truth) and in students' reports were labelled and assigned to the correct subcategory. The ground truth and students' reports were compared to quantify students' documentation completeness.

RESULTS

Next to the nine deductively selected main categories, 61 subcategories were defined. A total of 8943 items were labelled in the 123 interview transcripts (ground truth), compared with 5870 items labelled in students' reports (65.6% completeness of students' reports compared with ground truth). The main category personal details overlapped with 94.2% between students' report and ground truth in contrast to the main category with the highest discrepancy, allergy, with 41.1% overlap. Pertinent negative items and non-numerical quantifications were often missed.

CONCLUSIONS

Medical students show incomplete documentation of medical history interviews. Therefore, accurate documentation should be taught as an important goal in medical education.

Healthcare Provider Feedback Improves Outpatient E/M Billing and Coding in Otolaryngology Clinics

Objective

Discrepancies in medical coding can negatively impact institutional revenue and result in accusations of medical fraud. The objective of the present study was to prospectively assess the utility of a dynamic feedback system for otolaryngology providers in improving the coding/billing accuracy of outpatient clinic encounters.

Methods

A billing audit of outpatient clinic visits was performed. Dynamic billing/coding feedback, consisting of a virtual lecture and targeted e-mails, was provided at distinct intervals by the institutional billing and coding department. χ ² was used for categorical data, and the Wilcoxon test was used to compare changes in accuracy over time.

Results

A total of 176 clinic encounters were reviewed. Prior to feedback, 60% of encounters were inaccurately billed by otolaryngology providers, requiring upcoding and representing a potential 35% work relative value unit (wRVU) loss of E/M generated productivity. After 1 year of feedback, providers significantly increased the accuracy of their billing from 40% to 70% (odds ratio [OR]: 3.55, p < .001, 95% confidence interval [CI]: 1.69, 7.29), with a corresponding decrease in potential wRVU loss from 35% to 10% (OR: 4.87, p < .001, 95% CI: 0.81, 10.51).

Discussion

Dynamic billing feedback significantly improved outpatient E/M coding among otolaryngology healthcare providers in this study.

Implications for Practice

This study demonstrates that educating providers on appropriate medical coding and billing policies, while providing dynamic, intermittent feedback, may improve billing accuracy, translating into appropriate charges and reimbursements for services provided.

Assessing the quality of electronic medical records as a platform for resident education

BACKGROUND

Previous studies have assessed note quality and the use of electronic medical record (EMR) as a part of medical training. However, a generalized and user-friendly note quality assessment tool is required for quick clinical assessment. We held a medical record writing competition and developed a checklist for assessing the note quality of participants' medical records. Using the checklist, this study aims to explore note quality between residents of different specialties and offer pedagogical implications.

METHODS

The authors created an inpatient checklist that examined fundamental EMR requirements through six note types and twenty items. A total of 149 records created by residents from 32 departments/stations were randomly selected. Seven senior physicians rated the EMRs using a checklist. Medical records were grouped as general medicine, surgery, paediatric, obstetrics and gynaecology, and other departments. The overall and group performances were analysed using analysis of variance (ANOVA).

RESULTS

Overall performance was rated as fair to good. Regarding the six note types, discharge notes (0.81) gained the highest scores, followed by admission notes (0.79), problem list (0.73), overall performance (0.73), progress notes (0.71), and weekly summaries (0.66). Among the five groups, other departments (80.20) had the highest total score, followed by obstetrics and gynaecology (78.02), paediatrics (77.47), general medicine (75.58), and surgery (73.92).

CONCLUSIONS

This study suggested that duplication in medical notes and the documentation abilities of residents affect the quality of medical records in different departments. Further research is required to apply the insights obtained in this study to improve the quality of notes and, thereby, the effectiveness of resident training.

An Interactive Multimodality Curriculum Teaching Medicine Residents About Oncologic Documentation and Billing

Introduction

Physicians recognize the importance of clinical documentation for accuracy of coding and billing, but it is emphasized little in residency curricula, with an even smaller emphasis on oncology-specific documentation. We developed an educational curriculum to teach residents about clinical documentation for cancer patients. Our tool kit includes didactics, simulated history and physical (H&P) documentation, and personal feedback.

Methods

A preintervention survey was first administered to gauge baseline knowledge. A simulated H&P was developed that required participants to complete their own assessment and plan. We delivered a 25-minute lecture regarding billing and coding along with documentation tips and tricks specific to hematology/oncology. Thereafter, we handed out a second H&P, and participants had to once again complete their own assessment and plan. These H&Ps were graded by three reviewers using a rubric. We then gave residents personalized feedback using the above data and administered a postintervention survey.

Results

The postintervention survey revealed that 100% of the residents surveyed found this activity helpful, 83% noted that further knowledge of diagnosis codes was helpful to their learning, 100% noted that that this activity taught them to improve documentation, 91% said they were more likely to use cancer-specific diagnoses, and 91% said they would benefit from direct feedback-based education.

Discussion

Didactic and formal education is more effective when combined with hands-on examples and direct personalized feedback.