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Surgery Resident Develops Documentation Training

UTGSM Surgery resident Dr. JeffcoachDavid Jeffcoach, MD, Surgery Resident, developed a training intervention focused on improving patient documentation. He hypothesized that such improvements would enhance documentation patterns and lead to improved patient outcomes. Through his training project, he helped his department meet the needs of increasingly complex surgical resident education standards. These standards included meeting the Next Acceditation System education milestones, the national implementation of the Patient Protection and Affordable Care Act, and decreasing resident education funding.

All Surgery residents participated, with each resident undergoing a one-on-one 30-minute intervention with Trey La Charite, MD, Clinical Documentation Integrity Specialist for The University of Tennessee Medical Center. During the meeting, residents reviewed the quality of their notations using current medical documentation practices. Charts were reviewed for all patients discharged from four surgical services over a one-month period, looking at patient demographics, length of stay, geometric mean length of stay, case mix index, and the improvement of patient care.

Following the intervention, a subsequent sample of surgical patients was evaluated using the same endpoints. All goals of the project were met: increased geometric mean length of stay, increased case mix index, and overall improved patient care.

Dr. Jeffcoach concluded that the intervention was a success in improving the practices of General Surgery residents in documentation and that his training was a valuable resource for preparing residents for practice as well as a strategy for improving patient care.

Posted October 23, 2014

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