An Educational Intervention to Improve Residents’ Inpatient Charting

Objective : This report describes an educational intervention designed to improve psychiatry residents’ inpatient charting skills. Methods : The residency training committee formed a multidisciplinary team to study the problem by using quality improvement principles. The team hypothesized that residents’ charting would improve with education about the purpose of the medical record and instruction on the specific components to document. The team designed an educational intervention to train residents to record five items in the chart of every inpatient: an admission note, an off-service note, descriptions of medication changes, daily progress notes, and the name and discipline of the individual recording these items. Prior to the educational intervention, a chart abstractor determined the frequency, with which residents charted the five items. Additional chart audits were conducted 1 month and 6 months following education. Results : Compliance in charting four of the five items improved significantly 1 month after education, and the improvement was maintained after 6 months. Conclusion : An educational intervention that is planned and implemented by a multidisciplinary team can enhance an area of resident performance that affects patient care.