Title: Specific educational intervention can improve quality of family practice residents’
clinical documentation in inpatient hospital records
Authors: Ruthann Russo, PhD, JD, MPH, RHIT, Ian L. Diener, MD, MBA, FAAFP, and
Gerard F. Klinzing, MD
Abstract
Documentation in medical records is translated into coded data that determines quality ratings and reimbursement. Documentation that is of high quality is likely to result in more accurate reimbursement and quality ratings. Studies have also found a positive relationship between high quality documentation and quality of patient care. This study used a documentation training intervention. The training was structured using the four constructs of self-efficacy. Two 2-hour training sessions were provided to family practice residents. Twenty (20) residents participated in the training, but only 8 completed all of the training and study instruments. Documentation quality and self-efficacy were measured before and after the intervention. There was an improvement in self-efficacy and documentation quality. Only the improvement in documentation quality was statistically significant. This preliminary research has important implications for similar studies with larger groups and comparison or control groups to provide results that are better able to be generalized.
