Assessing medical student documentation using simulated charts in emergency medicine

Abstract

BackgroundThe 1995 Health Care Financing Administration (HCFA) guidelines stated that providers may only use the review of systems and past medical, family, social history in student documentation for billing purposes; therefore, many providers viewed the student documentation as an extraneous step and chose not to allow medical students to document patient visits. This workflow negatively affected medical student education in documentation skills. Although the negative impact on students’ documentation skills is obvious, areas of deficits are unknown. Understanding the area of deficits will benefit future curriculums to prepare prospective resident physicians for proper documentation. We aimed to assess areas of deficits in documentation of fourth-year medical students according to HCFA billing guidelines.MethodsWe conducted a prospective study of fourth-year medical students’ simulated chart documentations at a United States medical school from May 2014 to May 2015. We evaluated students’ simulated charts from an online learning tool using simulated cases for completeness according to HCFA guidelines and analyzed data using descriptive statistics.ResultsWe found that 98.9% (n = 90) of the charts were downcoded. Of these charts, 33.0% (n = 30) had incomplete history of present illness, 90.1% (n = 82) had incomplete review of systems, 73.6% (n = 67) had incomplete past medical, family, social history and 88.8% (n = 80) had incomplete physical exams.ConclusionNew curriculum should include billing guideline information and emphasize the completeness of charts according to acuity.

How Pharmaceuticals Mask Health and Social Inequity

“…21,22 A subsidiary industry of physician conferences, medical billing specialists, and undergraduate and graduate medical curricula have been developed to teach physicians how to code to maximize reimbursement, with little reflection on the biological narratives that shape this economy. 23,24,25 Medical necessity determinations, CPT and Z codes, and RVUs elevate, incentivize, and monetize biomedical expertise and interventions, which in turn shape the everyday work of physicians and health care systems. 26 Physicians confronted with patients' complex social needs face financial pressures that are in conflict with their desire to engage in the complexity of their patients' sociostructural lives, despite the profound effect such engagement would have on illness trajectories.…”

Pupil Prose Appraisal: Four Practical Solutions to Medical Student Documentation and Feedback in the Emergency Department

“…Even so, students may reap patient care skills improvement from use of EMR templates including improvements in medical student objective structured clinical examination scores with template use . Without the use of an EMR, most medical student notes lack complete or appropriate details with regard to a clinical encounter of a patient with chest pain and would be down‐coded with respect to reimbursement guidelines . Experience with EMRs is necessary to develop appropriate efficiency and skills, and limiting students’ ability to document has been shown to have consequences on medical training .…”

Improving Medical Student Inpatient Documentation Through Feedback Using a Note Assessment Tool

“…Effective feedback has been shown to be an important tool for increasing the quality of physician and student clinical performance [ 12 - 15 ]. However, most of these studies on student note quality involved standardized patients or simulated environments, which may not reflect real patient-doctor encounters in an inpatient or clinical setting [ 8 , 16 - 17 ].…”