SHM Converge Scientific Abstract ePoster Gallery-Maximizing Accuracy, Minimizing Queries: A Clinical Documentation Improvement Initiative for Internal Medicine Residents

Maximizing Accuracy, Minimizing Queries: A Clinical Documentation Improvement Initiative for Internal Medicine Residents

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This initiative introduced a clinical documentation improvement (CDI) curriculum for internal medicine interns, aiming to reduce documentation queries by 10% for the top ten queried diagnoses over a six-month period. The program addressed a gap in residency education, since formal CDI training is often absent despite its importance for severity-of-illness documentation, billing, and systems-based practice.<br /><br />The intervention included interactive, peer-led lectures, refinement of EMR smart phrases, and case and mortality review sessions. Thirty-seven interns completed a pre-survey and answered 65% of knowledge-based documentation questions correctly. After the curriculum, 33 interns completed a post-survey and scored 97% correct, showing strong knowledge gains. All respondents reported that the lecture was helpful, that they learned something, and that they could apply the information in the future.<br /><br />Although resident engagement and knowledge retention were excellent, the project did not meet its goal of reducing queries by 10%. Overall queries decreased by 6%, but specificity-related queries increased by 2%. The team is conducting further internal validation to better understand how to translate improved knowledge into reduced administrative burden.<br /><br />Future work will focus on identifying barriers to applying CDI concepts in clinical practice, improving use of EMR tools, and developing a longitudinal curriculum that expands into broader systems-based practice topics such as patient status and billing.

Asset Subtitle

Alaina Mui

Meta Tag

Author List Alaina Mui, Colleen McIntosh, Gloria Jackson, Ryan Cobb

Category Innovations

Concept Clinical Documentation

Concept Disease Severity

Concept Clinical Documentation Improvement

Concept Specificity

Concept Documentation Accuracy

Distinguished Non-Finalist

Presenter Organization University of South Florida

Presenting Author Alaina Mui

Track Quality Improvement

Keywords

clinical documentation improvement

CDI curriculum

internal medicine interns

documentation queries

resident education

EMR smart phrases

knowledge assessment

severity of illness documentation

billing

systems-based practice

Clinical Documentation

Disease Severity

Clinical Documentation Improvement

Specificity

Documentation Accuracy