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.
Keywords Diagnosis writing, medical record, medical records documentation, education, residency training, performance change
Declaration of Interests No conflicts of interest declared
