Clinical documentation training for residents

Residency Program Insider, September 23, 2016

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Increasing accountability in medicine has brought more attention to the importance of clinical documentation as medical errors are publicly reportable and certain kinds of errors are required to be reported to CMS, says Joseph Cristiano, MD, assistant professor of general internal medicine at Wake Forest Baptist Health in Winston-Salem, North Carolina. However, clinical documentation training for physicians has historically been lacking.

“We’ve neglected this area by no ill-will intent. Documentation as performed by physicians has evolved and the audience has evolved as well … We’re playing catch up now and recognizing this is an area of weakness,” says Cristiano, who provides clinical documentation training for residents, medical students, and faculty.

When training residents, he finds that they want to know the actual specifics of what is required of them in their role as trainees. Residents are particularly interested in knowing exactly what billing elements are required of them in a given encounter type.

Editor’s note: Cristiano will present a free HCPro webcast, Effective Strategies for Teaching and Supervising Resident Clinical Documentation, on October 11 at 1 PM ET. Click here to register.

Source: Residency Program Alert

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