3529 - Impact of Didactic Instruction upon Medicolegal Quality of Radiation Oncology Resident Physician Documentation

C. Kriegler¹, A. Duimering², V. Patel³, and S. Loewen⁴; ¹University of Alberta, Edmonton, AB, Canada, ²Cross Cancer Institute, Edmonton, AB, Canada, ³University of Alberta, Faculty of Medicine and Dentistry, Edmonton, AB, Canada, ⁴Department of Oncology, University of Calgary, Calgary, AB, Canada

Purpose/Objective(s): Effective clinical record-keeping is crucial for the practice of Radiation Oncology (RO). There is uncertainty if RO residents are aware of, and adhere to, medicolegal documentation guidelines. We aimed to assess the impact of an educational intervention on RO residents’ knowledge of medicolegally sound clinical documentation and documentation quality. We hypothesized that our educational intervention would be viewed as useful by participants, increase knowledge of clinical documentation, and improve quality of participant’s post-intervention clinical record-keeping. Materials/

Methods: Anonymous pre- and post-seminar surveys were developed to assess resident perspectives and knowledge acquisition using 5-point Likert scale questions, descriptive feedback, and a knowledge test. Grading rubrics to assess quality of initial consultation and follow-up notes were derived from guidelines established by the American College of Radiology, the American Society for Radiation Oncology, and the Canadian Medical Protective Association. Residents from two institutions attended a didactic seminar on medicolegal documentation and were asked to complete the pre-/post-seminar surveys and submit samples of their consult and follow-up notes within 3 months preceding (6 notes) and 1 month after (6 notes) the seminar. Pre- and post-seminar survey data and documentation quality scores were compared using paired t-test.
Results: Fourteen residents completed pre-/post-seminar surveys and attended the seminar, while 11 submitted documentation. None had prior medicolegal documentation education, nor were they aware of available resources. Post-seminar, participants had a better understanding of documentation (2.79 vs. 3.43, p=0.045*) and informed consent (2.71 vs. 3.79, p=0.002*); knowledge test scores increased (86.6% vs. 95.5%, p=0.001*), as did guideline adherence scores for consult (69.8% vs. 79%, p=0.001*) and follow-up notes (55% vs. 75.2%, p<0.001*). All indicated that the seminar added value to their training and 93% believed their documentation would improve.
Conclusion: Our survey revealed that improvements are needed for medicolegal documentation training during residency training and demonstrated that one didactic education session significantly enhanced residents’ knowledge base and documentation quality. Our findings support a recommendation to incorporate mandatory medicolegal documentation training into RO residency curricula.