Effective medical record documentation
is required to support accurate capture of diagnoses, patient acuity (case mix index [CMI]), and justify resource utilization for reimbursement. Billing code complexity and a lack of formal documentation education
in training programs have created a need for academic medical centers to incorporate training for trainees (residents, fellows, and new nurse practitioners). We hypothesized that standardized stroke
note templates, trainee education
, and feedback from chart audits would improve documentation
To improve the accurate/complete capture of expected (E) length of stay (LOS) and CMI by designing/implementing ischemic and hemorrhagic stroke
templates containing high-frequency complication and comorbidity diagnoses with the greatest impact on stroke
populations, combined with trainee education
and chart audits.
Descriptive statistics were used for outcomes before/after implementation of the templates. Primary outcomes include ELOS and CMI. Wilcoxon rank-sum test or chi-square test was used for group comparison.
The post-template group demonstrated a significant improvement in ELOS from 5.84 to 8.27 days (p
< .0001). Case mix index increased (1.73–1.75; p
< .0001) in the post-template group.
-specific templates, trainee education
, and chart audits were associated with significant improvement in documentation
accuracy and an improved business model of stroke
care in our hospital.