Measuring Medical Documentation Accuracy: A Novel Approach Offering Reproducible Objective Measurements Across...

Medical documentation is an important component of healthcare delivery and represents a significant portion of physician assistant educational efforts. Assessing proficiency in documentation is challenging, often relying on the subjective evaluation of documents. This study presents a novel approach using video-recorded provider-patient interactions and an interactive scoring rubric. Sixty-five participants, representing three cohorts, completed medical documentation with each document receiving accuracy scores from three independent scorers. Using this approach, the consistency of two versions of a provider-patient encounter with the same chief complaint but variable details was demonstrated (p = 0.239). Inter-scorer reliability using this method was maintained across participants with an average variation of 1.21 points on a 54-point scale between three independent scorers. Applying this method to evaluate educational preparedness, a statistically significant increase in accuracy was identified in cohorts approaching the completion of didactic education (p < 0.05). The method presented here provides a reliable platform to access medical documentation accuracy across educational levels and documentation styles.