Training can improve inpatient record documentation

By medwireNews Reporters

The accuracy and completeness of inpatient medical records can be significantly improved with clinical interventions designed to develop quality record keeping, research shows.

The most effective quality improvement efforts include peer demonstration, observation, and practice, which are all important constructs of self-efficacy.

The findings "provide considerable support for greater resource investment" toward training physicians in improving clinical documentation quality (CDQ), report Ruthann Russo (University of New York/Borough of Manhattan Community College, USA) and colleagues.

Writing in the Health Care Management Review, the researchers point out that while clinical documentation is critical to healthcare quality and cost, medical students, residents, and physicians receive almost no training in it.

Numerous studies have recognized the poor quality of clinical records. For example, one study showed that as many as 80% of terminal cancer patients did not have code status documented in their electronic medical records.

In their study, Russo and colleagues wanted to include self-efficacy as part of the CDQ training protocol. Self-efficacy influences behavior through mastery, vicarious experience, social persuasion, and psychologic states.

Social persuasion involves teaching by credible, trustworthy experts and the psychologic aspect of self-efficacy involves enhancing the learner's physical status and reducing their stress levels, explains the team.

The study tested two CDQ training protocols: the first employed all four constructs of self-efficacy, while the two-construct protocol did not include an opportunity to practice CDQ during training or vicarious learning.

Overall, both training approaches increased the quality of clinical documentation, with large and significant improvements when comparing the CDQ pre-test with the post-test CDQ

In both models, the 91 participating internal medicine residents were more likely to document patient history and diagnosis, etiology of disease based on patient symptoms, and clinical significance of abnormal tests after training than beforehand. The documentation was also performed in a manner that met the hospital and Medicare requirements for coding.

However, the four-construct self-efficacy model resulted in significantly better results than the two-construct protocol.

"Only the full four-construct training has a positive impact on post-training self-efficacy," conclude Russo and colleagues. "Given the benefits of four-construct training, health care systems should adopt the four-construct approach to CDQ training employed in this research."

Since publishing their training approach, multiple health care organizations, including 12 academic medical centers and 46 acute care hospitals, have trained their medical staff using the four-construct protocol.

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