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Factors associated with evaluation & management error rates of medical students
Dissertation   Open access

Factors associated with evaluation & management error rates of medical students

Gina Yacovelli
Doctor of Health Science (D.H.Sc.), Drexel University
27 Feb 2023
DOI:
https://doi.org/10.17918/00002001
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Abstract

Physicians--Training of Medical records--Management Medical records--Evaluation Medical records--Study and teaching
Background: Medical record documentation skills play a vital role in various facets of healthcare. Medical students gain their knowledge of medical record documentation by way of formal curriculum-based training during medical school as well as on-the-job training as a resident. Practical experiential learning is useful but is also limited regarding exposure to the depth and breadth of documentation guidelines and practices. Previous research regarding medical documentation skills for medical students has shown that structured, curriculum-based training does not diminish the documentation error rates of medical students. Objective: The primary hypothesis is that existing curriculum-based E&M training of medical students is not adequate enough to yield documentation error rates to within an acceptable range. The acceptable benchmark range is no more than 10% error, meaning a 90% accuracy rate. Methods: Using a retrospective observational cohort design, this study aims to assess medical student Evaluation & Management (E & M) documentation skills. Results: The results indicate that the current curriculum-based E&M training is not sufficient enough to yield less than or equal to a 10% error rate. Thus, once medical students graduate and become credentialed providers, they are likely faced with a steep learning curve to complete clinical E&M documentation on par with their physician peers. Conclusion: There is a need for revised curriculum-based E & M training in order to address deficiencies in the current training model.

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