Background: Unconscious bias within the U.S. health care system has been linked with disparities in the treatment of patients by age, gender, and race (1). While many factors contribute to these disparities, implicit bias may play a significant role. Stigmatizing language often reflects the implicit bias that healthcare providers possess toward patients (2). Recent research […]

Background: Stigmatizing language in clinical notes can negatively impact physician attitudes, propagate bias, affect prescribing behaviors, and exacerbate healthcare disparities, yet remains prevalent even in the Open Notes era. Prior analyses of stigmatizing terms in clinical notes are limited by the lack of context in which terms are used and multiple meanings of certain words […]

Background: The importance of accurate patient documentation for effective medical communication and financial compensation is well-documented. However, appropriate medical billing based on medical documentation is not emphasized in graduate medical education. We performed a review and analysis of resident charting errors during inpatient rotations to improve documentation and billing skills. Methods: A retrospective study was […]

Background: There is no formal curriculum for medical students, residents or advanced practitioner students on appropriate clinical documentation improvement (CDI). As the primary documenters for medical records, several studies have shown benefit in billing, coding and hospital metrics with trainee education [1-2]. Despite this, there remains a scarcity of education on documentation for residents and […]

Background: The importance of accurate patient care records for effective communication and medical education is well documented. However, medical documentation as a tool for financial compensation is not emphasized in graduate medical education. We performed a review and analysis of resident charting errors during inpatient rotations to determine the potential revenue loss and economic impact. […]

Background: A problem list serves as a central place for hospital-based clinicians to obtain a comprehensive and concise view of the patient’s active medical conditions. Use of the hospital problem list has many potential benefits: it provides a mental model of patient’s health status; streamlines the documentation process; makes chart review more efficient; facilitates communication […]

Background: Many hospitalized adults arrive with pre-existing malnutrition, which is associated with high risk of adverse outcomes. As such, malnutrition is a common variable in cost and quality risk adjustment models based on hospital discharge diagnosis codes. Hospital dietitians assess patients for malnutrition and generally document the details of their evaluations. However, coding professionals cannot […]

Background: Malnutrition is a significant indicator for illness severity and expected mortality. Prior to any process improvement interventions in 2014, only 4.7% of UNMH inpatients were diagnosed with malnutrition at discharge, much lower than the published national inpatient prevalence of 20-50%. Given the relatively high level of poverty in NM, we believe these lower rates […]

Background: The Vizient Quality and Accountability scorecard is a tool that measures academic medical centers (AMCs) clinical performance, focusing on quality and safety while targeting specific opportunities for improvement. The Vizient quality domains include Mortality, Efficiency, Effectiveness, Equity, Patient Experience, and Patient safety. In an academic setting, the frontline healthcare providers are resident physicians. As […]