A Structured Workshop to Improve Chart Documentation Among Housestaff

Abstract

OPEN ACCESSSeptember 4, 2009A Structured Workshop to Improve Chart Documentation Among Housestaff Jaideep Talwalkar, MD, Jason Ouellette Jaideep Talwalkar, MD Yale School of Medicine Google Scholar More articles by this author , Jason Ouellette Saint Marys Hospital Department of Medicine Google Scholar More articles by this author https://doi.org/10.15766/mep_2374-8265.5095 SectionsAbout ToolsDownload Citations ShareFacebookTwitterEmail AbstractAbstract Introduction: This resource is a series of workshops designed to assist internal medicine residents in developing chart documentation skills. In a series of hour-long workshops, notes written by house staff in both the inpatient and outpatient settings are used as a springboard for discussion. Together with faculty, house staff critique the notes and score them using instruments developed for this purpose. Methods: This resource was designed specifically for use with international medical graduates, who often face communication barriers with patients, staff, and faculty due to differences in language and culture, but can be used with any group of internal medicine trainees. Program materials can be modified to suit the needs of educators in other fields of medicine. This resource addresses the Accreditation Council for Graduate Medical Education requirement that internal medicine residency programs review “clinical documentation for format, quality of data entry, accuracy of the assessment, and appropriateness of the plan.” Results: In a preimplementation needs assessment, house staff revealed that they value feedback related to chart documentation and would like more formal education in this area. Faculty members also placed value on the teaching of note-writing skills, and were particularly interested in improving the quality of hospital discharge summaries. In extemporaneous commentary, house staff have stated that they consider points learned from this resource on a regular basis during their daily work. House staff have also reported that they have a better understanding of the expected format and content of various notes. A formal postimplementation program evaluation is in progress and will include analysis of house staff self-reported confidence and satisfaction as well as a chart review to measure actual change in quality of notes. Discussion: Internal medicine training programs may improve the quality of house staff chart documentation by implementation of this structured series of interactive workshops. House staff value feedback related to their own chart documentation skills, but may be hesitant to publicly provide this feedback to their peers. Educational Objectives By using these workshops, instructors will be able to: Teach house staff the essential elements required in chart documentation in the inpatient and outpatient settings.Demonstrate the utility of chart note review for quality improvement and performance evaluation.Improve the quality of house staff notes.Provide residency administration with objective evaluation of residents' written communication skills. Sign up for the latest publications from MedEdPORTAL Add your email below FILES INCLUDEDReferencesRelatedDetails FILES INCLUDED Included in this publication: Introduction to READ.ppt READ Instructor's Guide.doc READ Workshop Bibliography.doc Progress Note Indiv Feedbk Temp.xls Progress Note Indiv Feedbk frm.pdf Progress Note Indiv Feedbk frm.doc Progress Note Chart Ext Instru.pdf Progress Note Chart Ext Instru.doc Office Visit Indiv Feedbk Temp.xls Office Visit Indiv Feedbk frm.pdf Office Visit Indiv Feedbk frm.doc Office Visit Chart Ext Instru.pdf Office Visit Chart Ext Instru.doc Inpat Adm Indiv Feedbk Temp Resident.xls Inpat Adm Indiv Feedbk Temp Intern.xls Inpat Adm Indiv Feedbk frm Resident.pdf Inpat Adm Indiv Feedbk frm Resident.doc Inpat Adm Indiv Feedbk frm Intern.pdf Inpat Adm Indiv Feedbk frm Intern.doc Inpat Adm Chart Ext Instru.pdf Inpat Adm Chart Ext Instru.doc Disch Sum Indiv Feedbk Temp.xls Disch Sum Indiv Feedbk frm.pdf Disch Sum Indiv Feedbk frm.doc Disch Sum Chart Ext Instru.pdf Disch Sum Chart Ext Instru.doc To view all publication components, extract (i.e., unzip) them from the downloaded .zip file. Download editor’s noteThis publication may contain technology or a display format that is no longer in use. Copyright & Permissions© 2009 Talwalkar and Ouellette. This is an open-access publication distributed under the terms of the Creative Commons Attribution-NonCommercial-Share Alike license.KeywordsACGMEProgress NoteChart DocumentationForeign GraduatesHistory TakingEducational Measurement Disclosures None to report. Funding/Support None to report. Loading ...