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Grand Rounds: Improving Coding Accuracy via Clinical Documentation Improvement Education


By Theodore DeMartini, MD , Assistant Professor, Department of Pediatrics, Penn State Health Milton S. Hershey Medical Center

Objectives (Educational Content) :

1. Describe the importance of documentation for communication, quality monitoring, and reimbursement. 2. Illustrate best documentation practices in the inpatient and outpatient settings. 3. Present a documentation improvement project using education and resource tools.

Target Audience:

General pediatricians, family physicians, nurse practitioners, physician assistants, social workers, psychologists, and nurses.

Identified Gap:

Studies have shown that many providers are not trained to document. Surveys have shown that 80% of pediatric residents believed their documentation training was inadequate.1 26% of emergency medicine residents felt there was sufficient training]ng on documentation and billing with only 9% and 15% stating they could bill correctly or understand coding respectively.2 Adult neurologists 100% of survey respondents felt they had insufficient training in documentation. Note audits performed in that same study showed that only 44% were accurate and 24% had complete information.

Estimated Time to Complete the Educational Activity:

1 hour(s)

Expiration Date for CE/CME Credit:


Method of Participation in the Learning Process:

The learner will view the presentation, successfully complete a post-test and complete an activity evaluation.

Evaluation Methods:

All learners must successfully complete a post-test, as well as an activity evaluation, to claim CE/CME credit.


Theodore DeMartini, MD, has indicated that he has no financial relationships with any ineligible companies.

Accreditation Statement:

Children’s Hospital Medical Center of Akron is accredited by the Ohio State Medical Association to provide continuing medical education for physicians.

CHMCA designates this enduring material activity for a maximum of 1.0 AMA PRA Category 1 Credit TM.  Physicians should only claim the credit commensurate with the extent of their participation in the activity.


Aiello, F. A., Judelson, D. R., Durgin, J. M., Doucet, D. R., Simons, J. P., Durocher, D. M., Flahive, J. M., & Schanzer, A. (2018). A physician-led initiative to improve clinical documentation results in improved health care documentation, case mix index, and increased contribution margin. Journal of Vascular Surgery, 68(5), 1524–1532.

Andreae, M. C., Dunham, K., & Freed, G. L. (2009). Inadequate training in billing and coding as perceived by recent pediatric graduates. Clinical Pediatrics, 48(9), 939–944.

Arndt, B. G., Beasley, J. W., Watkinson, M. D., Temte, J. L., Tuan, W. J., Sinsky, C. A., & Gilchrist, V. J. (2017). Tethered to the EHR: Primary care physician workload assessment using EHR event log data and time-motion observations. Annals of Family Medicine, 15(5), 419–426.

Baksh, A. S. (2018). UTHSC Digital Commons The Importance of Clinical Documentation Improvement The Importance of Clinical Documentation Improvement.

Centers for Medicare & Medicaid Services. (2016). Design and development of the Diagnosis Related Groups (DRG). October, 1–14.

Courtright, E., Diener, I., & Russo, R. (2004). Clinical documentation improvement. The Case Manager, 15(1), 46–49.

Dawson, B., Carter, K., Brewer, K., & Lawson, L. (2010). Chart smart: a need for documentation and billing education among emergency medicine residents? The Western Journal of Emergency Medicine, 11(2), 116–119.

Evans, D. V, Cawse-lucas, J., Ruiz, D. R., Allcut, E. A., Andrilla, C. H. A., & Norris, T. (2015). Family Medicine Resident Billing. Fam Med, 47(3), 175–181.

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