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Training Osteopathic Medical Students for Drastic 2021 Health Record Documentation Policy Changes

Journal: The Journal of the American Osteopathic Association Date: 2020/12, 120(12):Pages: e47-e48. doi: Subito , type of study: cross sectional study

Full text    (https://www.degruyter.com/document/doi/10.7556/jaoa.2020.157/html)

Keywords:

cross sectional study [872]
documentation [8]
medical students [671]
osteopathic medicine [2072]
USA [1725]

Abstract:

Statement of Significance: Osteopathic medicine has traditionally viewed the body as a unit. Understanding the patient includes gathering the patient's needs, concerns and experiences in order to make an accurate diagnosis and formulate an effective treatment plan. Rational treatment, for acute problems and chronic disease management, is dependent on effective patient-provider communication. In light of emerging policies, which eliminate requirements to document the History or Examination in outpatient health records, we need to be certain the patient's History and Exam are not clinically disregarded. Research Methods: Osteopathic medical students, while displaced from clinical rotations due to the COVID-19 pandemic, were offered a 3½ hour mini-course as part an accommodative curriculum to understand existing and emerging federal health record documentation policy changes. The course viewed issues through the lens of American Osteopathic Association (AOA) Core Competencies: Systems-Based Practice (SBP) and Practice-Based Learning & Improvement (PBLI). Surveys, administered through a QualtricsTM generated email after each of 4 sessions, were approved by Touro University California's Institutional Review Board [M-0920]. Participation in the Zoom based mini-course began with a brief Introduction, followed by a survey and an assignment to view a 32-minute AOA Evaluation and Management scoring webinar. A 45-minute presentation on the next day explored issues from a SBP viewpoint: explaining ‘why' current policies are in place and ‘why' new changes are occurring. After the SBP session and survey, participants were invited to complete a History on themselves utilizing a free online patient empowerment tool at www.PreHx.com. The following day, another 45-minute session addressed ‘how' to accommodate policy changes through the lens of PBLI. After this session and survey, participants were assigned to review a 2017 JAOA article where patients were invited to author the History component of their own health record. The final session reviewed survey results and conducted active discussion. Data Analysis: Surveys sent to osteopathic medical students were analyzed by the University's QualtricsTM software. As per IRB protocols, all data was de-identified prior to analysis. Results: 79 of a class of 134 students consented to participate in the first survey, which revealed 58% learned on the day of education that starting January 1, 2021 documentation of the History and Examination in outpatient health records will no longer be linked to provider payment. 43% strongly agreed and 36% agreed in the belief that documentation of the History is important to determining an accurate diagnosis, formulating an effective treatment plan and sharing information with all health care professionals. After the mini-course, 80% agreed/strongly agreed to feeling optimistic that health record documentation policies are going to make the practice of medicine more meaningful for patients and providers. 68%, with agreed and strongly agreed responses, support this type of training for all medical students. In addition, 85% of study participants believe guidelines need to be offered in response to these changing policies so providers, ancillary medical staff members and patients can best function. Conclusion: This study identifies a need to educate medical students of drastic 2021 health record documentation policy changes. While osteopathic medical students feel confident new policies will improve the practice of medicine for all stakeholders, they recognize a need for training and guidelines.


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