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Clinical Documentation Integrity for Resident Trainees

Recently, Dr. Joseph Cristiano did a Talk Ten Tuesdays DocTalk segment on his experience educating residents on clinical documentation at Wake Forest University.

We received a follow-up question from Suzanne, so I am focusing this article on more details about resident training. During my stint as physician advisor (PA) at University Hospitals Health System in Cleveland, I taught hundreds of students, residents, and fellows. And I am going to share my experiences with you.

It is likely obvious to you that educating residents is of paramount importance. After all, who does the lion’s share of the documenting in academic institutions? If you get them to do it correctly, the patient care and quality metrics improve, and you avert queries.

One concern in the healthcare industry is that residents and chiefs have difficulty finding time for dedicated educational sessions. This is because each residency program has a specific curriculum that needs to be covered over the entire course of the training program. You’d be surprised at how quickly the educational competencies, as defined by the Accreditation Committee on Graduate Medical Education (ACGME), eat away at the total weekly resident conference time allotted. Of course, resistance against formal instruction on clinical documentation is not confined to trainees, either.

Several times a year, I give a two-day course teaching documentation to practicing providers (, many of whom have gotten in trouble with their medical boards. Unanimously, the attendees express how they wish they had been taught good documentation practices early on in their careers. The reality is that trainees get very little guidance on documentation from their attendings, because often they are not well-versed themselves. As a PA, I spent countless hours giving residents specific feedback on their documentation, which I had assessed in the course of my chart reviews.

Have you ever heard someone ask, “What’s in it for me?” Residents can be like children; they don’t stay young forever. Eventually, they go out on their own, and we know that quality metrics are dependent on each practitioner’s actions and outcomes, as well as the documentation of their protegees. I assert that the information we have to impart is important to them, even if they don’t initially recognize what is in it for them.

Acknowledging that the agenda of my intensive medical record-keeping course seemed to meet the physician attendees’ needs, I set up a “business of medicine” curriculum for the internal medicine residents. I designed it to give them three sessions over their three years of training. The introductory session, given during orientation, deals with good documentation practices and risky documentation behavior. The key points are:

  • Tell the story. Documentation is for clinical communication.
  • Tell the truth. Make the patient look as sick in the electronic medical record (EMR) as he or she looks in real life.
  • Limit copying and pasting, and be sure to always mindfully edit.

The bottom line is my business motto: Put “mentation” back into “documentation.”

The next session addresses how quality is judged in medicine. Historically, healthcare providers were unaware that their quality and outcomes were being objectively judged. Now, there are report cards and dashboards and websites that display quality metrics and compare providers and institutions. Providers need to understand how their documentation demonstrates how sick and complex their patients are. They need to understand the concept of “observed over expected.”

Once you have that foundation, you can understand the specific clinical documentation integrity (CDI) conditions in context. Providers learn best with case-based examples. I also recommend ensuring relevance; obstetricians do not relish hearing about vascular surgery conditions.

The final session details the requirements for evaluation and management coding. This is the basis for billing for their own reimbursement when they get out into the real world. Now that risk adjustment is moving into the outpatient arena, if each resident understands diagnosis-related groups, it is easier to leap to hierarchical condition categories and population health management. It reinforces the concept of making the patient looks as sick in the EMR as he or she looks in real life.

CDI is bolstered by constant exposure and repetition, and resident education is a continuous process. Residents should be the point of first contact for queries, since they are often doing much of the documenting. CDI tips should get posted in the residents’ charting areas. Pocket cards can be distributed at the beginning of rotations, often at a short CDI presentation. PAs should be giving grand rounds or lectures, whenever solicited.

CDI personnel may find rounding with a multi-disciplinary team including trainees quite fruitful. University Hospitals residents do a week-long quality rotation (I actually had several choose to shadow me for a month-long rotation), during which they participate in, and contribute to, mortality review conference.

There may be opportunities for CDI specialists to attend specific service line conferences, such as surgical morbidity and mortality conference. And any of you who ever read anything I have written before will know that I am a huge proponent of directed feedback. Redacting and distributing feedback to an entire division or department can be an efficient way to disseminate information.

The most crucial factor for a trainee education program to be successful is for the CDI team to believe that they are contributing to the trainees’ education. You must trust that you are helping the provider and the patient. You must be confident that improved documentation, which demonstrates severity of illness and complexity, actually improves patient care. If the message the residents get is that it is really all about maximizing the hospital’s bottom line, then it is doomed to fail. CDI is important, and you need to teach trainees whenever and wherever you can.

We’d love to hear about your experiences. If you have instituted a successful program to educate trainees, or have a tale of failure to share as a warning, please send me an email.

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Erica E. Remer, MD, CCDS

Erica Remer, MD, FACEP, CCDS, has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, CDI, and ICD-10 expertise. As physician advisor for University Hospitals Health System in Cleveland, Ohio for four years, she trained 2,700 providers in ICD-10, closed hundreds of queries, fought numerous DRG clinical determination and medical necessity denials, and educated CDI specialists and healthcare providers with engaging, case-based presentations. She transitioned to independent consulting in July 2016. Dr. Remer is a member of the ICD10monitor editorial board and is the co-host on the popular Talk Ten Tuesdays weekly, live Internet radio broadcasts.

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