Pilot study on documentation skills: is there adequate training in emergency medicine residency?
BACKGROUND
Thorough and accurate documentation in the medical record is important, and documentation skills should be an integral component of emergency medicine (EM) residency training.


OBJECTIVE
We sought to study the documentation skills of EM residents as they relate to emergency department (ED) reimbursement.


METHODS
This was a retrospective, cross-sectional study. We reviewed all charts of patients presenting to the adult ED during a 2-week period. We compared three groups: patients seen primarily by an EM resident, patients seen primarily by a physician assistant (PA), and patients seen primarily by an attending emergency physician. Outcome measures were the incidence of downcodes and dollars lost to downcodes in all groups.


RESULTS
There were 212 patients in the resident group, 683 patients in the PA group, and 437 patients in the attending group. There were 12 downcodes (5.7%, 95% confidence interval [CI] 2.96-9.70) in the resident group, 10 downcodes (1.5%, 95% CI 0.70-2.68) in the PA group, and 17 downcodes (3.9%, 95% CI 2.28-6.14) in the attending group (p = 0.002). The mean dollar lost per patient seen in the resident group was $3.21 (95% CI 1.41-5.00); $0.91 (95% CI 0.33-1.49) in the PA group; and $2.23 (95% CI 1.17-3.28) in the attending group (p = 0.002).


CONCLUSIONS
Charts documented primarily by EM residents were more likely to be downcoded than charts documented primarily by PAs or ED attendings. This downcode rate resulted in a greater loss of revenue in the resident group. We believe this represents an area for improvement in EM residency education.
Weizberg
Moshe
M
Department of Emergency Medicine, Staten Island University Hospital, Staten Island, New York 10305, USA.
Cambria
Bartholomew
B
Farooqui
Yusra
Y
Hahn
Barry
B
Dazio
Francesca
F
Maniago
Eric Matthew
EM
Berwald
Nicole
N
Kass
Dara
D
Ardolic
Brahim
B
D003430:Cross-Sectional Studies; D004635:Emergency Medicine / Q000193:education*; D004636:Emergency Service, Hospital / Q000458:organization & administration; D006801:Humans; D007396:Internship and Residency / Q000592:standards*; D008499:Medical Records / Q000191:economics / Q000592:standards*; D010823:Physician Assistants; D010820:Physicians; D010865:Pilot Projects; D012189:Retrospective Studies