SHM Converge Scientific Abstract ePoster Gallery-Novel Education and Standardized Documentation Improves Accuracy of Illness Capture

Pdf Summary

This study describes a peer-led clinical documentation improvement (CDI) program for internal medicine residents at USF, designed to reduce documentation queries and improve accuracy in medical records. Because formal CDI education is limited for trainees, the team created a curriculum with the hospital CDI staff and resident peers, focusing on the eight most frequently queried diagnoses. These were converted into “smart phrases” with standardized diagnostic wording and supporting clinical details. The intervention also included monthly workshops during ward rotations, posters, and reminder cards in team rooms and on computers.<br /><br />All 178 internal medicine residents participated. The program’s goal was to reduce documentation queries by 25%, but results were stronger than expected: total queries decreased by 64% over 18 months, falling from 181 in the baseline period to 49 in the final 4-month period. Workshop attendance was 100%, and smart phrases were used 114 times in the final study period. More than half of participants reported using the phrases in at least half of their documentation, and post-intervention satisfaction was 100%.<br /><br />Improved documentation also affected hospital performance metrics. After normalization, expected length of stay increased from 6.52 to 6.64, case mix index rose from 1.67 to 1.78, and expected mortality increased from 2.09 to 2.36, suggesting better illness capture and documentation accuracy.<br /><br />The authors conclude that peer-to-peer education combined with stakeholder-developed smart phrases can significantly reduce commonly misdocumented diagnoses and improve important hospital metrics. They recommend expanding the program to other diagnoses and departments and studying whether it reduces documentation burden and time spent charting.

Asset Subtitle

Alan D. Roberts

Meta Tag

Author List Alan D. Roberts, Colleen McIntosh, Elizabeth Romes, Jean Claude Guidi, Jorden E. Smith

Category Research

Concept Clinical Documentation Improvement

Concept Medical Record

Concept Medical Documentation

Concept Documentation Query

Concept Documentation Quality

Distinguished Non-Finalist

Presenter Organization University of South Florida

Presenting Author Alan D. Roberts

Track Quality Improvement

Keywords

clinical documentation improvement

CDI program

internal medicine residents

documentation queries

medical records accuracy

peer-led education

smart phrases

resident training

hospital metrics

diagnosis documentation

Clinical Documentation Improvement

Medical Record

Medical Documentation

Documentation Query

Documentation Quality