Conference conversations: Nagao shares her resident documentation tips
Editor’s note: Stacey Nagao, BSN, RN, CCDS, is a CDI specialist at University Health System in San Antonio, Texas. Nagao will be presenting a poster at the 2018 ACDIS Conference entitled “How to write a note: Development of a resident documentation curriculum.” Make sure to stop by the dedicated poster viewing session on Day 2, 10:45-11:30 a.m. and see Nagao’s and all the other presenters’ posters.
Q: What made you want to submit a poster this year? How did you decide on a topic?
A: We want to share the physician education curriculum we developed and hear from other, similar, CDI programs to see how it can be improved or possibly implemented at other institutions. We decided on the topic because our CDI program is focusing on provider education as a vital area in improving chart accuracy.
Q: What was your first step in developing your resident documentation curriculum?
A: We needed to meet the educational needs of different types of learners. We decided to focus on interns at the beginning of the year to cover introductory topics. We also developed case studies based on common opportunities on the inpatient general medicine service with the assistance of our physician champion. In the spring, we lead a case-based presentation with small group activities. The residents are placed in small groups to discuss the case studies and “improve” the notes. The identified opportunities are then discussed in the large group setting.
Q: Why, in your opinion, is it important to educate residents in documentation?
A: In most academic healthcare systems, residents provide the majority of patient care documentation. In addition to acquiring clinical skills, residents are now expected to provide notes that meet billing and regulatory requirements. We created an innovative resident education curriculum in electronic health record documentation to meet the critical need for training residents in these important skills.
Q: Did you collaborate with any other departments while developing the curriculum? If so, which ones and why?
A: We worked closely with our physician champion and the coding educator for the providers. We understand that documentation affects both the provider and hospital billing/coding, so we wanted to make sure to include all aspects in our education.
Q: What's one thing you're excited for at the ACDIS 2018 conference?
A: We are excited to learn more about what other CDI programs are doing and possibly implement or improve what we’re currently working on.