Is Teaching Residents How to Code a Valuable Intervention? [16N]

Abstract

INTRODUCTION: Appropriate documentation is an important component of quality health care. In academic medical centers, most documentation is done by residents. Given the scope of topics for resident education, a formal curriculum for documentation is often non-existent. Poor documentation has important consequences, including financial loss and compromise of quality indices. We sought to determine if instructing residents in basic coding principles improved the rate of appropriate documentation for early-term deliveries. METHODS: Residents were given a one-hour lecture focused on inpatient documentation, with a section on documenting appropriate justification for early-term deliveries. Subsequent documentation over a one-week period by each of the second- and third-year residents in attendance (n=7) was reviewed, and the rate of appropriate documentation for early-term deliveries was compared to similar documentation prior to the intervention for the same residents. This was compared to documentation by second- and third-year residents who did not attend the lecture (n=9). RESULTS: There were 153 total encounters analyzed. 29 were for patients who underwent early-term delivery. Of the pre-intervention early-term deliveries, the reasons for delivery in 8/13 (61.5%) were incorrectly documented. Of the post-intervention early-term deliveries, the reasons for delivery in 6/16 (37.5%) were incorrectly documented. 5/6 (83.3%) of the post-intervention early-term deliveries which were incorrectly documented were by residents who had not attended the lecture. CONCLUSION: Teaching residents coding and formal documentation is a valuable intervention. These simple interventions stand to make a significant impact on both financial and quality indices. These interventions will also serve to better prepare trainees for their transition into practice.