An Innovative Curriculum Using a Simulated Electronic Health Record to Teach Internal Medicine Residents About...

Area of Science:

• Medical Education
• Health Informatics
• Clinical Documentation

Background:

• The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) is essential for patient care, billing, and public health.
• Accurate ICD-10-CM coding knowledge is critical for physicians entering independent practice.

Purpose of the Study:

• To introduce internal medicine residents to the ICD-10-CM coding system.
• To enhance residents' understanding and application of ICD-10-CM codes in clinical practice.

Main Methods:

• A 3-session module was developed for internal medicine residents at all training levels.
• The module utilized a simulated patient encounter within an electronic health record.
• Pre- and post-module tests were administered to assess knowledge acquisition.

Main Results:

• 88% of learners found the exercise useful, with significant improvement in posttest scores.
• 94% of learners committed to using appropriate ICD-10-CM codes post-module.
• The module was integrated into the ambulatory curriculum due to its effectiveness.

Conclusions:

• The developed module is an effective tool for teaching ICD-10-CM coding to residents.
• Proficiency in ICD-10-CM coding enables physicians to improve documentation specificity and appropriateness.