A pilot study of the impact of an educational intervention aimed at improving medical record documentation.
INTRODUCTION
Studies have shown the importance of medical staff education in improving chart documentation and accuracy of medical coding. This study aimed to examine the effect of an educational intervention on recording medical diagnoses among a sample of medical residents based at Kashan University of Medical Sciences.


METHODS
This pilot study was conducted in 2010 and involved 19 residents in different specialties (internal medicine, obstetrics and gynecology, and surgery). Guidelines for recording diagnostic information related to surgery, obstetrics and internal medicine were taught at a five-hour lecture. Five medical records from each resident from before and after the educational intervention were assessed using a checklist based on relevant diagnostic information related to each discipline. Data were analysed using a paired t-test and Wilcoxson signed rank test.


RESULTS
There was no improvement in the quality and accuracy of the recording of obstetric diagnoses (type, place, outcome and complications of delivery) after the training. There was also no effect on the documentation of underlying causes and clinical manifestations of disease by internal medicine and surgery residents (p=0.285 and p=0.584, respectively).


CONCLUSION
The single education session did not improve recording of diagnoses among residents. The gathering and recording of complete, accurate and high quality medical records requires interaction between the hospital management, health information management professionals and healthcare providers. It is therefore essential to develop a more sophisticated portfolio of strategies that involves these key stakeholders.
['Farzandipour|M|M|', 'Meidani|Z|Z|', 'Rangraz Jeddi|F|F|', 'Gilasi|H|H|', 'Shokrizadeh Arani|L|L|', 'Fakharian|E|E|', 'Saddik|B|B|']
D057189:Checklist D002983:Clinical Competence D004282:Documentation D013502:General Surgery D019983:Guideline Adherence D017408:Guidelines as Topic D006801:Humans D007388:Internal Medicine D007396:Internship and Residency D008499:Medical Records D009774:Obstetrics D010865:Pilot Projects D058996:Quality Improvement D012577:Schools, Medical D014495:Universities
education medical record medical records documentation Diagnosis writing performance change residency training