Pilot Study on Documentation Skills: Is There Adequate Training in Emergency Medicine Residency?

Background: Thorough and accurate documentation in the medical record is important, and documentation skills should be an integral component of emergency medicine (EM) residency training. Study Objective: We sought to study the documentation skills of EM residents as they relate to emergency department (ED) reimbursement. Methods: This was a retrospective, cross-sectional study. We reviewed all charts of patients presenting to the adult ED during a 2-week period. We compared three groups: patients seen primarily by an EM resident, patients seen primarily by a physician assistant (PA), and patients seen primarily by an attending emergency physician. Outcome measures were the incidence of downcodes and dollars lost to downcodes in all groups. Results: There were 212 patients in the resident group, 683 patients in the PA group, and 437 patients in the attending group. There were 12 downcodes (5.7%, 95% confidence interval [CI] 2.96–9.70) in the resident group, 10 downcodes (1.5%, 95% CI 0.70–2.68) in the PA group, and 17 downcodes (3.9%, 95% CI 2.28–6.14) in the attending group (p = 0.002). The mean dollar lost per patient seen in the resident group was $3.21 (95% CI 1.41–5.00); $0.91 (95% CI 0.33–1.49) in the PA group; and $2.23 (95% CI 1.17–3.28) in the attending group (p = 0.002). Conclusion: Charts documented primarily by EM residents were more likely to be downcoded than charts documented primarily by PAs or ED attendings. This downcode rate resulted in a greater loss of revenue in the resident group. We believe this represents an area for improvement in EM residency education.