Documentation Improvement and Residents Core Competency in Practice‐Based Learning and Improvement and System‐Based Practice

Background:

National data on clinicians' documentation shows 60%‐80% inappropriate documentation on common hospital DRGs. We developed a documentation improvement project to improve clinicians' performance and to develop residents' core competency in system‐based practice (SBP) and practice‐based learning and improvement (PBLI).

Purpose:

To improve clinicians performance on appropriate documentation in hospitalized patients.

Description:

We collected data on clinicians' documentations on common hospital DRGs and found > 50% inappropriate documentations. The most common DRGs were congestive heart failure (CHF), sepsis, and acute renal failure (ARF). We developed clinicians' educational tools (clinical vignettes) on these DRGs based on best practices and presented to hospital director, program directors, and departmental chairs. We presented our educational tools in grand rounds, residents' conference, and departmental meetings. For internal medicine residents these conferences were the part of residents' education on SBP and PBLI. We performed residents' pretests and posttests and compared their performance before and after intervention to evaluate residents' performance in SBP and PBLI. We reviewed 10 charts on each DRG before and after intervention. Prior to the intervention 8 of 10 charts (80%) documented CHF inappropriately, 6 of 10 (60%] documented ARF inappropriately, and 7 of 10 (70%) documented sepsis inappropriately. After intervention CHF was documented inappropriately in only 1 chart (10%) and sepsis and ARF in 2 charts (20%). Our results show significant improvement in documentation of all 3 DRGs after intervention. Fourteen residents participated in pre‐ and posttests on documentation improvement. On pretest, CHF was documented inappropriately by 12 of 14 residents (35.71%), sepsis/SIRS was documented inappropriately by 10 of 14 (71.42%), and ARF by 9 of 14 (64.26%). On posttest, CHF was documented appropriately by all residents. Sepsis and ARF were documented inappropriately by only 2 of 14 residents (14.28%). Improvement in residents' performance on documentation reflects residents'competency on SBP and PBLI

Conclusions:

A quality improvement project on documentation is associated with improved learners' outcomes and improved clinicians' performance and also demonstrates residents' core competency in SBP and PBLI. This project may have a positive impact on the organization's performance. Further study is required.

Author Disclosure:

A. Roy, none.