Background: Severity of illness documentation is essential in capturing the complexity of patients to justify their hospital admission and inpatient level of care resources. Additionally, systems-based practice is a core competency for the ACGME. Residency programs do not typically have formal curriculum for items such as clinical documentation improvement. As such, residents in our system and their attendings regularly receive documentation queries. While documentation queries are used to help capture complexity, they unfortunately disrupt patient care and add to the administrative workload for residents and attending physicians. We aimed to improve documentation proactively to enrich resident education and decrease administrative harm. Previously, efforts for internal medicine residents focused on day-to-day documentation skills1. The use of smart phrases to improve documentation was demonstrated in outpatient rather than inpatient encounters2. Additionally, prior efforts aimed at improving compensation have been demonstrated at a department level for surgical specialties, rather than targeting residents3. We present a novel curriculum for internal medicine residents to improve clinical documentation, with a focus on improvement of specificity of diagnoses and capture of risk of mortality. We utilized multiple tools to support our efforts, including didactic presentations, interactive case and mortality reviews, and electronic medical record (EMR) smart phrases to support residents in capturing specific diagnoses and appropriate risk of mortality.
Purpose: We aimed to decrease queries sent to resident teams by 10% for our top ten diagnoses from July 2025 to December 2025. We used peer led didactic lectures, electronic medical record smart phrases, and interactive case reviews during dedicated academic time.
Description: We identified the top ten diagnoses queried to resident teams and developed interactive, peer led, didactic lectures to educate residents on documentation improvement. The education was given to all intern residents who are the primary documenters. We administered a pre-survey and feedback survey to all intern residents prior to their dedicated lecture time. Thirty-seven interns participated in the survey and achieved 65% correct on the knowledge-based documentation questions. Thirty-three residents completed our post-survey. 100% agreed or strongly agreed they found the lecture helpful, they learned something, and they can apply the information in the future. We plan to administer a similar test yearly to assess longitudinal learning of documentation. For senior residents, we reviewed cases with a gap in observed and expected mortality in a one hour session during dedicated academic lectures. We provided examples of diagnoses that were improperly documented or missing from the case and its impact on expected mortality, among other quality metrics. Our query results and smart phrase usage data are due December 2025.
Conclusions: There is no standard documentation improvement education focused on internal medicine residents. We developed a peer-led, multi-faceted approach to help residents understand and apply clinic documentation improvement. We are anxiously awaiting our results and how we can achieve proactive complexity capture while decreasing administrative harm.