A pilot study of the impact of an educational intervention aimed at improving medical record documentation

Farzandipour, M. and Meidani, Z. and Rangraz-Jeddi, F. and Gilasi, H.R. and Shokrizadeh Arani, L. and Fakharian, E. and Saddik, B. (2013) A pilot study of the impact of an educational intervention aimed at improving medical record documentation. Journal of the Royal College of Physicians of Edinburgh, 43 (1). pp. 29-34.

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Introduction: Studies have shown the importance of medical staff education in improving chart documentation and accuracy of medical coding. This study aimed to examine the effect of an educational intervention on recording medical diagnoses among a sample of medical residents based at Kashan University of Medical Sciences. Methods: This pilot study was conducted in 2010 and involved 19 residents in different specialties (internal medicine, obstetrics and gynecology, and surgery). Guidelines for recording diagnostic information related to surgery, obstetrics and internal medicine were taught at a five-hour lecture. Five medical records from each resident from before and after the educational intervention were assessed using a checklist based on relevant diagnostic information related to each discipline. Data were analysed using a paired t-test and Wilcoxson signed rank test. Results: There was no improvement in the quality and accuracy of the recording of obstetric diagnoses (type, place, outcome and complications of delivery) after the training. There was also no effect on the documentation of underlying causes and clinical manifestations of disease by internal medicine and surgery residents (p=0.285 and p=0.584, respectively). Conclusion: The single education session did not improve recording of diagnoses among residents. The gathering and recording of complete, accurate and high quality medical records requires interaction between the hospital management, health information management professionals and healthcare providers. It is therefore essential to develop a more sophisticated portfolio of strategies that involves these key stakeholders. © 2013 Royal College of Physicians of Edinburgh.

Item Type: Article
Additional Information: cited By 3
Uncontrolled Keywords: accuracy; article; cancer surgery; delivery; gynecology; human; internal medicine; medical documentation; medical education; medical record; obstetrics; pilot study; practice guideline; resident; Saudi Arabia, Diagnosis writing; education; medical record; medical records documentation; performance change; residency training, Checklist; Clinical Competence; Documentation; General Surgery; Guideline Adherence; Guidelines as Topic; Humans; Internal Medicine; Internship and Residency; Medical Records; Obstetrics; Pilot Projects; Quality Improvement; Schools, Medical; Universities
Subjects: Health Professions
Divisions: Faculty of Para medicine > Department of Management & Health Information Technology
Depositing User: editor . 2
Date Deposited: 03 Mar 2017 13:34
Last Modified: 28 May 2017 13:35
URI: http://eprints.kaums.ac.ir/id/eprint/664

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