Dataset Information
Education in Neurology Resident Documentation Using Payroll Simulation.
Ontology highlight
ABSTRACT: Background
Approaches for teaching neurology documentation include didactic lectures, workshops, and face-to-face meetings. Few studies have assessed their effectiveness.Objective
To improve the quality of neurology resident documentation through payroll simulation.Methods
A documentation checklist was created based on Medicaid and Medicare evaluation and management (E/M) guidelines. In the preintervention phase, neurology follow-up clinic charts were reviewed over a 16-week period by evaluators blinded to the notes' authors. Current E/M level, ideal E/M level, and financial loss were calculated by the evaluators. Ideal E/M level was defined as the highest billable level based on the documented problems, alongside a supporting history and examination. We implemented an educational intervention that consisted of a 1-hour didactic lecture, followed by e-mail feedback "paystubs" every 2 weeks detailing the number of patients seen, income generated, income loss, and areas for improvement. Follow-up charts were assessed in a similar fashion over a 16-week postintervention period.Results
Ten of 11 residents (91%) participated. Of 214 charts that were reviewed preintervention, 114 (53%) had insufficient documentation to support the ideal E/M level, leading to a financial loss of 24% ($5,800). Inadequate documentation was seen in all 3 components: history (47%), examination (27%), and medical decision making (37%). Underdocumentation did not differ across residency years. Postintervention, underdocumentation was reduced to 14% of 273 visits (P < .001), with a reduction in the financial loss to 6% ($1,880).Conclusions
Improved documentation and increased potential reimbursement was attained following a didactic lecture and a 16-week period in which individual, specific feedback to neurology residents was provided.
SUBMITTER: Liang JW
PROVIDER: S-EPMC5398143 | biostudies-literature | 2017 Apr
REPOSITORIES: biostudies-literature
Publications
Education in Neurology Resident Documentation Using Payroll Simulation.
Journal of graduate medical education 20170401 2
<h4>Background</h4>Approaches for teaching neurology documentation include didactic lectures, workshops, and face-to-face meetings. Few studies have assessed their effectiveness.<h4>Objective</h4>To improve the quality of neurology resident documentation through payroll simulation.<h4>Methods</h4>A documentation checklist was created based on Medicaid and Medicare evaluation and management (E/M) guidelines. In the preintervention phase, neurology follow-up clinic charts were reviewed over a 16-w ...[more]