Implications of Clinical Documentation (In)Accuracy: A Pilot Study Among General Surgery Residents.
Accurate and reliable medical records are necessary for assessing, improving, and reimbursing healthcare services. Clear and concise physician documentation is essential to assuring accurate and reliable medical records. Yet, prior literature reveals surgery residents do not receive adequate, beneficial education on medical record documentation and coding. This is concerning because the evaluation of and reimbursement for healthcare service delivery relies on the physician's ability to produce appropriate medical records, which then get translated into billable codes. This pilot study suggests hospitals may incur significant financial loss in revenue due to inaccurate clinical documentation by residents. Thus, educational training for medical residents in the area of clinical documentation and hospital-specific coding practices may prove financially advantageous.
a Health Services Research & Development, Michael E. DeBakey Veterans Affairs Medical Center , Houston , Texas , USA.|b Department of General Surgery , University of Texas Health Science Center , San Antonio , Texas , USA.
Andrea
A
Garcia
c Department of Management , Policy and Community Health, University of Texas Health Science Center at Houston School of Public Health , Houston , Texas , USA.
Lee
L
Revere
a Health Services Research & Development, Michael E. DeBakey Veterans Affairs Medical Center , Houston , Texas , USA.
Sherene
S
Sharath
a Health Services Research & Development, Michael E. DeBakey Veterans Affairs Medical Center , Houston , Texas , USA.|d Operative Care Line, Michael E. DeBakey Veterans Affairs Medical Center , Houston , Texas , USA.|e Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery , Baylor College of Medicine , Houston , Texas , USA.
Panos
P
Kougias
D002983:Clinical Competence / Q000191:economics* / Q000592:standards*; D004282:Documentation / Q000191:economics / Q000592:standards* / Q000706:statistics & numerical data; D013502:General Surgery / Q000191:economics / Q000193:education* / Q000295:instrumentation; D006801:Humans; D007396:Internship and Residency / Q000592:standards; D019300:Medical Errors / Q000517:prevention & control; D008499:Medical Records / Q000592:standards / Q000706:statistics & numerical data; D010865:Pilot Projects; D012189:Retrospective Studies; D000078329:Workforce
Medical records; accurate; coding; medical documentation; resident education; revenue