Documenting resident procedure and diagnostic experience: simplifying the process

Area of Science:

• Medical Education
• Healthcare Administration

Background:

• Residency Review Committees (RRC) mandate documentation of resident procedural and diagnostic experiences.
• Hospital privileging often relies on documented prior clinical experience.
• Residency programs require efficient, user-friendly data collection and reporting tools.

Purpose of the Study:

• To outline a simplified, user-friendly method for documenting resident procedural and diagnostic experiences.
• To meet the data documentation needs of family practice residency programs.

Main Methods:

• Development of a pocket-sized, optically scannable card for data input.
• Implementation of a computerized database with report generation capabilities.
• Utilization of diagnostic clusters to streamline the data input process.

Main Results:

• The system incurred initial setup costs of approximately $10,000 and annual maintenance/operational fees of about $5,000.
• Substantial increase in resident submission of documentation information after system implementation.

Conclusions:

• The system effectively meets RRC and hospital privileging documentation requirements.
• Provides a valuable tool for resident evaluation and optimizing training opportunities.
• Enables simplified, accurate documentation for potential program, state, and national resident comparisons.