Best Practices in Medical Documentation: A Curricular Module

Objective To create and validate a checklist for high-quality documentation and pilot a multi-modal, immersive educational module across multiple institutions. We hypothesized that this module would improve knowledge, skills, and attitudes in medical documentation. Methods Module design was grounded in an established curriculum design framework. We conducted the study across 12 pediatric critical care fellowship programs between September 2017 and January 2018. Workshops were allotted 90 minutes for completion. We utilized a pre-/post- study design to determine the workshop's impact. Changes in knowledge were assessed through pre and post testing. Changes in skills were evaluated with a validated checklist for inclusion of key documentation elements. Changes in attitudes were determined through learner self-assessment Results 83 of 138 eligible fellows (60%) started the module and 62 of 83 (75%) completed data sets for analysis. Immediate post-testing demonstrated modest statistically significant improvement in knowledge, skills, and attitudes. The workshop was easily disseminated and deployed Conclusions This study demonstrates that a multi-modal educational intervention can lead to improvement in medical documentation knowledge, skills, and attitudes in a cohort of PCCM fellows and be easily disseminated for use by other specialties and types of clinicians.

目的 创建并验证一份高质量医疗文书的清单，并在多个机构试点一个多模式、沉浸式教育模块。我们假设该模块将提高医疗文书方面的知识、技能和态度。 方法 模块设计基于一个已确立的课程设计框架。我们在2017年9月至2018年1月期间在12个儿科重症监护专科医师培训项目中开展了这项研究。研讨会安排90分钟完成。我们采用前 - 后研究设计来确定研讨会的影响。通过前后测试评估知识的变化。使用一份经过验证的包含关键文书要素的清单评估技能的变化。通过学习者自我评估确定态度的变化。 结果 138名符合条件的专科医师中有83名（60%）开始使用该模块，83名中有62名（75%）完成了数据集以供分析。即时的后测试显示在知识、技能和态度方面有适度的统计学显著改善。该研讨会易于传播和推广。 结论 这项研究表明，一种多模式的教育干预措施可以提高一组儿科重症监护医学（PCCM）专科医师在医疗文书方面的知识、技能和态度，并且易于传播，可供其他专业和类型的临床医生使用。