Education in Neurology Resident Documentation Using Payroll Simulation

Liang, John; Shanker, Vicki

doi:10.4300/jgme-d-16-00235.1

Cited by 8 publications

(15 citation statements)

References 11 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Studies across the nation have highlighted inadequate training for house staff with regard to billing and coding. 3 One report suggested that 82% of residents do not receive adequate training for billing and coding. 1 Careful clinical documentation is essential not only for billing but also for communication, education, data collection, quality management, and research.…”

Section: Introductionmentioning

confidence: 99%

“…1 Careful clinical documentation is essential not only for billing but also for communication, education, data collection, quality management, and research. 3,4…”

Section: Introductionmentioning

confidence: 99%

“…Several published papers have sought to improve documentation through tool kits, didactics, and personal feedback. 1,3–5,8–14 Economic journals have also focused on medical documentation. 2 Several studies have reported that educational sessions improve technical aspects of coding.…”

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

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

et al. 2018

View full text Add to dashboard Cite

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.

show abstract

Section: Introductionmentioning

confidence: 99%

“…1 Careful clinical documentation is essential not only for billing but also for communication, education, data collection, quality management, and research. 3,4…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

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

et al. 2018

View full text Add to dashboard Cite

show abstract

“…1 Educational interventions have been shown to result in improved documentation and increases in potential reimbursement. 2 We conducted a resident-led review of inpatient documentation to test the hypothesis that deficiencies in clinical documentation were responsible for incomplete International Classification of Diseases, 10th Revision (ICD-10) coding, which may have led to hospitalizations exceeding expected LOS.…”

Section: Q-tipmentioning

confidence: 99%

Effect of a Resident-Led ICD-10 Code-Focused Review of Inpatient Documentation on Length of Stay

et al. 2018

View full text Add to dashboard Cite

“…For example, Baker et al [ 3 ] developed an interpretive summary, differential diagnosis, explanation of reasoning, and alternatives assessment tool to assess comprehensive new patient admission notes. Liang et al [ 8 ] created a checklist for neurology residents” documentation. These tools are used for a specific section in medical records or a neurology department, which may not be practical for other specialties.…”

Section: Introductionmentioning

confidence: 99%

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

et al. 2021

View full text Add to dashboard Cite

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.

show abstract

Education in Neurology Resident Documentation Using Payroll Simulation

Abstract: Background Approaches for teaching neurology documentation include didactic lectures, workshops, and face-to-face meetings. Few studies have assessed their effectiveness.

Cited by 8 publications

References 11 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

Effect of a Resident-Led ICD-10 Code-Focused Review of Inpatient Documentation on Length of Stay

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

Contact Info

Product

Resources

About