Improving physician clinical documentation quality: evaluating two self-efficacy-based training programs.

Area of Science:

• Medical Education
• Health Informatics
• Quality Improvement

Background:

• Clinical documentation quality (CDQ) is vital for healthcare quality and cost, yet training for medical professionals is often inadequate.
• Existing CDQ training frequently omits crucial self-efficacy components like vicarious learning and mastery practice.
• Resource-intensive training incorporating these self-efficacy constructs may offer superior outcomes, justifying investment.

Purpose of the Study:

• To evaluate the impact of clinical documentation quality (CDQ) training on clinician self-efficacy and performance.
• To compare the effectiveness of training designs utilizing two versus all four self-efficacy constructs.

Main Methods:

• Ninety-one internal medicine residents participated in a study at a major academic medical center.
• Participants were randomized into two self-efficacy-based training groups or a control group.
• Clinical documentation quality (CDQ) and self-efficacy were measured pre- and post-intervention, analyzed using structural equation modeling and regression.

Main Results:

• Both training interventions led to improvements in clinical documentation quality (CDQ).
• The training incorporating all four self-efficacy constructs demonstrated a significantly greater positive impact on CDQ.
• This comprehensive training also resulted in increased clinician self-efficacy.

Conclusions:

• Clinical documentation quality (CDQ) can be substantially improved and sustained through targeted physician training.
• Training designs that integrate all four self-efficacy constructs are more effective in enhancing CDQ and self-efficacy.