News: Residency education offers new avenue for CDI expansion

Residency education offers CDI professionals an opportunity to teach the next generation of physicians about the value of complete and accurate medical record documentation before they start practice on their own.

While residents frequently face documentation problems (more than many other barriers in their first years), they receive the least amount of education on the topic, according to Joseph A. Cristiano, MD, a hospitalist at Wake Forest Baptist Medical Center in Winston-Salem, North Carolina, who participated on the March 21 episode of Talk Ten Tuesday by the ICD10 Monitor.

Wake Forest’s resident training begins with onboarding to instill the need for proper documentation in residents’ minds, but doesn’t end there, says Cristiano who leads the facility’s curriculum development efforts.

“Throughout their training we offer continuing education using case-based examples to demonstrate the good and bad habits in their documentation,” Cristiano said.

Many CDI specialists find case studies a particularly helpful way to reach physicians. Residents are no different. Even though they are new to the field, they still speak the language of physicians. Case studies and examples provide concrete educational materials.

In many ways, Cristiano doesn’t find the resident’s poor documentation particularly surprising. Residents do not have the documentation experience, or even the clinical experience, to fully document accurately without additional education.

As the residents receive more and more in-depth clinical education, Wake Forest follows up that training with documentation training. The residents need to advance both skills at once, according to Cristiano.

Fitting more education into the residents’ busy days can be a challenge. Even CDI specialists working with full-fledged physicians often find it difficult to fit education into the physicians’ hectic workflows. The fact that residents already have existing educational time set aside can be a big advantage for CDI efforts, if it’s taken advantage of.

“We incorporate the clinical documentation training into their existing instructional morning report design. We actually replace one of the traditional morning reports with a session specifically focused on clinical documentation,” Cristiano said.

 Editor’s note: To listen to the complete Talk Ten Tuesday podcast, click here. To read a previous ACDIS Conference presentation covering resident education, click here. To access ACDIS’ library of physician education resources, click here.