Clinical Document Improvement in Surgical Residency Training

Accurate clinical documentation is essential for patient care, interdisciplinary communication, quality metrics reporting, and hospital reimbursement. Many hospitals face significant revenue losses due to inadequate or incomplete documentation.

A retrospective chart review was conducted at a 250-bed community hospital in Queens, NY, analyzing surgical coding queries from January 2021 to December 2023. Before 2021, clinical documentation improvement (CDI) queries were randomly assigned to residents or attendings. In 2021, a quality improvement initiative centralized queries to the administrative chief resident, who facilitated resolutions. Data, including query volume and response times, were extracted from 3M CDI software.

A total of 701 charts were reviewed for the study period. Prior to the intervention, CDI queries averaged 18 per month with a 67% response rate within 24 hours. Following centralization in 2021, query volume decreased to 9 per month by 2023, and the 24-hour response rate improved to 97%. The implementation of standardized templates and real-time coding reviews contributed to these improvements.

Centralizing CDI queries and integrating structured interventions into surgical training programs significantly improved documentation accuracy and response times. Enhanced collaboration between residents and CDI specialists positively impacted workflow efficiency, patient care, and hospital financial outcomes.