Improving Emergency Medicine Residency Documentation Training: A Needs Assessment Benjamin Schnapp MD; Sarah Sanders MD; William Ford MD Background Methods ConclusionsResults References To identify perceived areas of need in documentation education amongst junior emergency medicine residents of the Northwestern Medicine Residency Program Study Population: Junior residents were chosen as they were felt to be most likely to have the greatest knowledge gaps regarding documentation. Survey Design: An anonymous Google survey was developed by medical education faculty and ed to the PGY1 and PGY2 residents. Before distribution, the survey was reviewed and edited for content validity by an online cohort of medical educators and piloted on the target audience for relevance and clarity. The survey was anonymous to obtain the most honest responses regarding residents’ comfort and background regarding different aspects of documentation. A 5-point Likert scale was used to record answers to most questions, while others were free response. Survey Content: Questions addressed perceived competency in documenting for communication with other providers, billing, medicolegal reasons, attitudes towards documentations, barriers to effective documentation, as well as previous teaching and interest in further education on documentation The ACGME mandates teaching residents documentation skills. Both emergency medicine (EM) program directors and residents agree that proper documentation is not taught well during residency. However, the medical record is complex, serving simultaneously to communicate with other providers, bill for services, and mitigate medicolegal risk. The areas of documentation that residents feel most lacking in are not currently known. Objective Attitudes toward documentation education were highly favorable, with 96% of respondents somewhat or strongly interested in learning more. Residents felt weakest about their knowledge of how to chart to protect themselves medicolegally, with only 16% somewhat or completely agreeing that they know what to include in their charts. They felt best about documenting to communicate with other providers, with 50% of respondents somewhat or completely agreeing that other providers could understand the patient’s emergency room course by reviewing the chart. Confirming the current literature, there is a lack of teaching of proper documentation. Only 28% somewhat or completely agreeing that they learn about documentation while on shift whereas 16% somewhat or completely agree they learn about documentation while off shift. Next Steps: To create and implement a curriculum that fills these gaps which can be utilized by EM programs across the country to improve residents’ knowledge and efficacy with documentation. 1)Dawson B, Carter K, Brewer K, Lawson L. Chart Smart: A Need for Documentation and Billing Education Among Emergency Medicine Residents? Western Journal of Emergency Medicine. 2010;11(2): )Hospital ED Survey Reveals Growing Concerns. ACEP News, Emergency Medicine Connect Career and CME Guide. 2007, pp 12, 26. 3)Pines JM, Braithwaite S. Documentation and Coding Education in Emergency Medicine Residency Programs: A National Survey of Residents and Program Directors. The California Journal of Emergency Medicine. 2004; 5(1): )Stahmer SA, Ellison SR, Jubanyik KK, et al. Integrating the core competencies: proceedings from the 2005 Academic Assembly consortium. Acad Emerg Med. 2007; 14:80–94. 5)Weizberg M, Cambria B, Farooqui Y, Hahn B, Dazio F, Maniago EM, Berwald N, Kass D, Ardolic B. Pilot study on documentation skills: is there adequate training in emergency medicine residency? J Emerg Med. 2011;40(6): Response Rate: 25 of 30 (83%) of residents responded to the survey. Legend Agree (completely/somewhat) Neutral Disagree (completely/somewhat) 96% 28% 16% 68% 80% 50% 64% 20% 52% 8% 76% 16% 4% 29% 21% 28% 8%