The Effect of Educational Intervention on Medical Diagnosis Recording among Residents

Davaridolatabadi, Nasrin; Sadoughi, Farahnaz; Meidani, Zahra; Shahi, Mehraban

doi:10.5455/aim.2013.21.173-175

Cited by 12 publications

(14 citation statements)

References 16 publications

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“…Several factors might have contributed to the observed lack of improvement in obesity documentation and counseling. First, the didactic presentations may have been too short, did not require sufficient active resident participation, and/or were not motivational enough to change residents’ behavior ( 9 , 10 ). Long-term and persistent interventions with active resident participation may be more effective ( 11 , 12 ).…”

Section: Discussionmentioning

confidence: 99%

Effect of didactic lectures on obesity documentation and counseling among internal medicine residents

Ren

Ellison

Miller

et al. 2016

Journal of Community Hospital Internal Medicine Perspectives

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BackgroundScreening adult patients for obesity and offering appropriate counseling and treatment for weight loss is recommended. However, many healthcare providers feel ill-equipped to address this topic.ObjectiveWe examined whether didactic presentations lead to increased obesity documentation and counseling among internal medicine (IM) residents.MethodsWe reviewed medical records of patients seen at the IM Resident Continuity Clinic during April 2015. Residents were provided feedback at two didactic presentations during May 2015. To examine the effect of this intervention, we repeated medical record review during June 2015. For both reviews, we abstracted patient-specific (i.e., age, body mass index [BMI], race, sex, and number of comorbid diagnoses) and resident-specific (i.e., sex and training level) data as well as evidence of obesity documentation and counseling. We used logistic regression models to examine the effect of intervention on obesity documentation and counseling, adjusting for patient- and resident-specific variables.ResultsOf the 278 patients with BMI≥30 kg/m2, 139 were seen before and 139 after the intervention. Intervention had no effect on obesity documentation or counseling with or without adjustment for confounding variables (both P>0.05). In adjusted post-hoc analyses, each additional comorbidity increased the odds of obesity documentation by 8% (OR=1.08; 95% CI=1.05–1.11; P<0.001). In addition, as compared to postgraduate year (PGY) 1 residents, PGY-3 residents were 56% (OR=0.44; 95% CI=0.21–0.95; P=0.03) less likely to counsel obese patients.ConclusionsObesity is inadequately addressed in primary care settings, and didactic presentations were unable to increase obesity documentation or weight loss counseling. Future research to identify effective interventions is needed.

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Section: Discussionmentioning

confidence: 99%

Effect of didactic lectures on obesity documentation and counseling among internal medicine residents

Ren

Ellison

Miller

et al. 2016

Journal of Community Hospital Internal Medicine Perspectives

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“…Fisla found that discharge against medical advice in a hospital significantly was higher than discharge after recovery (13). …”

Section: Discussionmentioning

confidence: 99%

Discharge Against Medical Advice in the Pediatric Wards in Boo-ali Sina Hospital, Sari, Iran 2010

et al. 2013

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Introduction:Since children neither comprehended nor contribute to the decision, discharge against medical advice is a challenge of health care systems in the world. Therefore, the current study was designed to determine the rate and causes of discharge against medical advice.Methods:This descriptive cross-sectional study was done by reviewing the medical records by census method. Data was analyzed using SPSS software and x2 statistics was used to determine the relationship between variables. The value of P<0.05 was considered significant.Results:Rate of discharged against medical advice was 108 (2.2%). Mean of age and length of stay were 2.8±4 (SD).3 years old and 3.7±5.4 (SD) days, respectively. Totally, 95 patients (88.7%) had health insurance and 65 (60.2%) patients lived in urban areas. History of psychiatric disease and addiction in 22 (20.6%) of the parents were negative. In addition, 100 (92.3%) patients admitted for medical treatment and the others for surgery. The relationship of the signatory with patients (72.3%) was father. Of 108 patients discharged against medical advice, 20 (12%) were readmitted. The relationship between the day of discharge and discharge against medical advice was significant (ρ =0/03).Conclusion:Rate of discharge against medical advice in Boo-ali hospital is the same as the other studies in the same range. The form which is used for this purpose did not have suitable data elements about description of consequence of such discharge, and it has not shown the real causes of discharge against medical advice.

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“…Medical educators have tried various approaches to teach better documentation to medical students 13 and residents. 14,15 However, there has been very little published research in dental education regarding training students or residents in documentation and compliance issues. A recent systematic review concluded that "little has been published about which methods are most effective for teaching dental record-keeping skills."…”

Section: Resultsmentioning

confidence: 99%

Improving Documentation, Compliance, and Approvals in an Electronic Dental Record at a U.S. Dental School

Thierer

Delander

2017

Journal of Dental Education

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The aims of this study were to improve progress note documentation by dental students, achieve accurate and timely charge capture and treatment code and note approval, and determine the effectiveness of multiple interventions in improving overall documentation of patient encounters in the clinic of one U.S. dental school. The study, conducted in 2014-15, used a logic model to create a process to address documentation issues in the clinic's electronic dental record (EDR) and to assess the effectiveness of interventions. An initial documentation review using the EDR was performed to obtain a baseline measurement. A significant correlation was noted at baseline between poor documentation and unapproved treatment codes and notes. Unapproved treatment codes and corresponding documentation were then reviewed each month. Students who had the highest number of unapproved treatment codes were identified as potentially having documentation issues. These students were contacted and met individually with the associate quality and compliance officer to review documentation and charge practices. Large group education was also provided to key learners: dental students and supervising faculty members. Education consisted of an in-service event for faculty members and a Moodle site course on documentation for students. After one year, the results showed that documentation rates improved from an overall rate of 61% to 81% of required documentation elements being present in the progress note. Although this educational intervention was successful in significantly improving documentation of treatment in the EDR, 19% of the notes at the conclusion of the study were still missing key elements. Further research is necessary to determine whether the interventions will continue to improve documentation or if additional measures need to be taken.

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The Effect of Educational Intervention on Medical Diagnosis Recording among Residents

Cited by 12 publications

References 16 publications

Effect of didactic lectures on obesity documentation and counseling among internal medicine residents

Effect of didactic lectures on obesity documentation and counseling among internal medicine residents

Discharge Against Medical Advice in the Pediatric Wards in Boo-ali Sina Hospital, Sari, Iran 2010

Improving Documentation, Compliance, and Approvals in an Electronic Dental Record at a U.S. Dental School

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