Background and purpose: High quality clinical documentation is a fundamental skill for practicing physicians and important for quality improvement. However, documentation and coding are rarely integrated into medical education curricula and there is a lack of standard neurology curriculum on this topic. We developed and evaluated a teaching session on clinical documentation for neurology resident physicians.
Methods: The education consisted of a didactic session designed by a neurologist with content about risk-adjusted mortality, clinical documentation integrity (CDI), impact of documentation on patients, and neurology-specific documentation guidance. A pre-post survey design was used to compare baseline and post-intervention self-reported knowledge and attitudes.
Results: 61 responses were collected (37 pre- and 24 post-intervention). Residents had increased understanding of the impact of documentation on quality metrics (P = 0.004), risk-adjusted mortality (P < 0.0001), and impact on patients (P = 0.02). Attitude towards CDI education improved significantly (P = 0.0016), as well as agreement that CDI is important to resident physicians (P = 0.003). The portion of residents who agreed training on CDI is useful and valuable increased significantly (P = 0.004). 92% agreed this curriculum was useful, and 96% agreed they understood the role of CDI better after the session.
Conclusions: In this study of a teaching session for neurology residents on clinical documentation, we found this format of teaching was well-received and highly effective in improving resident attitudes and self-reported knowledge.
Keywords: clinical specialty; general neurology; neurohospitalist; outcomes; quality; techniques.
© The Author(s) 2024.