Best Practices in Medical Documentation: A Curricular Module

Area of Science:

• Medical Education
• Clinical Documentation Improvement
• Fellowship Training

Background:

• High-quality medical documentation is crucial for patient care and communication.
• Existing educational methods may not adequately address the complexities of clinical documentation.

Purpose of the Study:

• To create and validate a checklist for high-quality documentation.
• To pilot a multi-modal, immersive educational module for medical documentation.
• To assess the module's impact on knowledge, skills, and attitudes.

Main Methods:

• Grounded in a curriculum design framework, the study involved 12 pediatric critical care fellowship programs.
• A pre-/post- study design assessed the workshop's impact over 90 minutes.
• Knowledge, skills, and attitudes were evaluated through testing, a validated checklist, and self-assessment.

Main Results:

• 62 of 83 fellows completed data sets, showing statistically significant improvements in knowledge, skills, and attitudes post-intervention.
• The educational module demonstrated ease of dissemination and deployment across institutions.
• Immediate post-testing indicated modest but significant gains in documentation competency.

Conclusions:

• A multi-modal educational intervention effectively enhances medical documentation knowledge, skills, and attitudes in fellows.
• The developed module is easily disseminable and applicable to other specialties and clinician types.
• This study validates a novel approach to improving clinical documentation standards.