A Structured Workshop to Improve Chart Documentation Among Housestaff

Talwalkar, Jaideep S.; Ouellette, Jason R.

doi:10.15766/mep_2374-8265.5095

Cited by 9 publications

(9 citation statements)

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“…Several MedEdPORTAL publications have addressed clinical documentation through didactics, testing, and small-group discussions. 16–22 No current publication exists for combining didactics, hands-on learning, and personal feedback as an effective teaching tool in a 1-hour session. This curriculum focuses on internal medicine resident documentation skills for the inpatient setting.…”

Section: Introductionmentioning

confidence: 99%

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

et al. 2018

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IntroductionPhysicians 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.MethodsA 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.ResultsThe 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.DiscussionDidactic and formal education is more effective when combined with hands-on examples and direct personalized feedback.

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Section: Introductionmentioning

confidence: 99%

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

et al. 2018

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“…A search of MedEdPORTAL found a resource created to help internal medicine residents improve their chart documentation. 7 The workshop was focused on international medical graduates and did not utilize an EHR. Based upon previous successful models of improving write-ups, 8 we created an interactive session to teach residents about effective discharge summaries.…”

Section: Introductionmentioning

confidence: 99%

Transitions of Care: Improving the Quality of Discharge Summaries Completed By Internal Medicine Residents

Black

Colford

2017

MedEdPORTAL

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Introduction: Discharge summaries are now the accepted means of communication in transition from inpatient to ambulatory care. However, there is often no formal residency education on this critical document, leading to discordance in discharge summaries written by internal medicine residents. There is little in the literature focusing on teaching how to effectively create a discharge summary using an electronic health record (EHR). Methods: A 1-hour workshop was designed to teach components of the discharge summary and how to utilize this document to safely transition patients from the inpatient to the ambulatory setting. One or two faculty facilitators led the workshop with approximately 20 resident learners. A 50-point rubric was created to assess effectiveness of discharge summaries pre-and postworkshop. Results: The workshop was well received by residents and median scores on the rubric improved from 39 to 45 (p < .001) postworkshop. Discussion: We found that by teaching the concepts using examples of discharge summaries written by our residents, and then creating a standardized EHR template, residents wrote more effective discharge summaries with increased focus on the transition to the ambulatory provider. These materials can be applied to other programs and levels of learners to improve discharge summary quality. This serves to provide a resource to those at other institutions looking to create a more formalized didactic session on discharge summaries with a particular focus on transitioning care to the ambulatory provider.

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“…9 Other than these areas, a broad literature search revealed little guidance outlining a specific acculturation curriculum to introduce and instill the necessary competencies during pediatric training. 10 To date, MedEdPORTAL has published two curricula pertaining to IMGs: one addressing internal medicine residents' chart documentation skills, 11 and the other addressing asking difficult questions, with only a partial focus on IMGs. 12 Neither specifically addresses acculturation.…”

Section: Introductionmentioning

confidence: 99%

The Acculturation Toolkit: An Orientation for Pediatric International Medical Graduates Transitioning to the United States Medical System

et al. 2020

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Introduction: International medical graduates (IMGs) consistently contribute to the US physician workforce. In fact, 25% of practicing pediatricians in the US are IMGs, highlighting the needs of IMG trainees. IMGs face unique challenges with acculturation compared to their peers due to unfamiliarity with the US medical system, especially the dynamics around patient-centered care. The literature supports the need for formal acculturation curricula. Methods: A cohort of program directors who train pediatric IMGs coupled findings from the literature with local themes from IMG focus groups to identify topics for an acculturation curriculum. Three small-group workshops utilized didactics, discussion, and role-play to cover topics related to patient-centered care, challenging communication with patients, complex psychosocial histories, and health literacy. The pilot was modified based on feedback and to enhance generalizability. The resulting four-module curriculum with presentations and supplemental materials is presented here. Results: After a 3-year pilot with 36 PGY 1 trainees, postcurriculum surveys reported 8.1 out of 10 in workshop satisfaction, plus increased knowledge and skills related to patient-centered care and communication with patients. Role-plays were the favorite activity. A 1-year follow-up survey reported the workshops to be influential on satisfaction with patient relationships and easing transition to residency. Discussion: A pilot acculturation curriculum addressing needs of pediatric IMG trainees was well received by participants and improved their comfort level in addressing challenging patient-communication scenarios. Pediatric programs that train IMGs can incorporate this curriculum to aid residents' transition to clinical practice in the US.

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A Structured Workshop to Improve Chart Documentation Among Housestaff

Cited by 9 publications

References 0 publications

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

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

Transitions of Care: Improving the Quality of Discharge Summaries Completed By Internal Medicine Residents

The Acculturation Toolkit: An Orientation for Pediatric International Medical Graduates Transitioning to the United States Medical System

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