Publication | Health Care Management Review 38:1

Improving Physician Clinical Documentation Quality

Ruthann Russo, Stephen Fitzgerald, J.D. Eveland, Barry Fuchs, and Patrick Redmon

January/March 2013

Clinical documentation is critical to healthcare quality and cost. The generally poor quality of such documentation has been well recognized, yet medical students, residents, and physicians receive little or no training in it. When clinical documentation quality (CDQ) training for residents and/or physicians is provided, it excludes key constructs of self-efficacy: vicarious learning (e.g., peer demonstration) and mastery (i.e., practice). CDQ training that incorporates these key self-efficacy constructs is more resource intensive. If such training could be shown to be more effective at enhancing clinician performance, it would support the investment of the additional resources required by healthcare systems and residency training programs.

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