Examining efforts to improve residents’ knowledge of documentation, coding

Standards on coding and clinical documentation are improving, but most residency programs lack education and training. In a study published in the Journal of Surgical Education, researchers evaluated residents’ current knowledge and examined the effect of an educational session on knowledge improvement.

Without the proper education, residents are unable to keep up with the changing guidelines of clinical documentation and coding. This study evaluated residents’ current knowledge and the effectiveness of an educational session in improving overall knowledge and awareness in clinical documentation and coding.

The study included 32 orthopedic residents that were all asked to complete a baseline assessment, attend a 45-minute lecture, complete a post session examination and asked to self-rate their level of comfort in coding and documentation on a scale of 1-5.

Results showed, although baseline scores were the same for junior and senior residents, a correlation between higher postgraduate level of training and higher ratings of self-perceived comfort levels. The educational session significantly improved average post session exam scores.

“The current healthcare environment necessitates better physician awareness regarding clinical documentation guidelines and coding principles,” wrote first author Matthew A. Varacallo, MD, and colleagues. “Very few adjustments to incorporate these teachings have been made to most residency training curricula, and the lack of time and resources remains the concern of many surgical programs. We have demonstrated that orthopedic resident knowledge in these important areas drastically improves after a single, high-yield 45-minute teaching session.”