Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland.
Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland.
J Surg Educ. 2018 Jul-Aug;75(4):1052-1057. doi: 10.1016/j.jsurg.2017.12.002. Epub 2017 Dec 27.
The purpose of this study is to determine whether orthopedic resident and fellow case logs accurately reflect trainee case volume.
For each orthopedic case performed at our institution between 7/1/14 and 10/31/14, the names of trainees who participated were obtained from the chart. The trainee Accreditation Council for Graduate Medical Education case logs were queried to determine if the procedure in question was logged and, if so, which current procedural terminology (CPT) codes were reported. The CPT codes reported by the trainees were compared to those reported by the attendings in the billing database. To ascertain the opinions of trainees regarding coding, a survey was conducted.
University of Maryland Medical Center (Baltimore, MD), a tertiary and quaternary care center which features a state-wide trauma referral center as well as orthopedic residency and fellowship training programs.
All orthopedic surgery residents and fellows present at the institution during the study period.
Trainees failed to log their cases 24% of the time (465/1925), including 25% (283/1117) for residents and 23% (182/808) for fellows (p = 0.16). Among cases that were logged, CPT codes were missed 46% of the time (673/1460) and extra codes were added 28% of the time (412/1460) compared to the attendings. In the survey, most trainees stated that it was "extremely" or "very" important for them to be able to code correctly (83%; 29/35).
In this study of orthopedic trainee case logging practices, cases were not logged 24% of the time. Caution should be taken with activities which rely on trainee case logs given the potential for inaccuracy.
本研究旨在确定骨科住院医师和研究员的病例记录是否准确反映学员的病例量。
对于我们机构在 2014 年 7 月 1 日至 10 月 31 日之间进行的每一例骨科手术，从病历中获取参与的学员的姓名。查询学员的研究生医学教育认证委员会病例记录，以确定所讨论的手术是否有记录，如果有记录，则报告哪些当前程序术语 (CPT) 代码。将学员报告的 CPT 代码与计费数据库中报告的主治医生的代码进行比较。为了确定学员对编码的看法，进行了一项调查。
马里兰大学医学中心（巴尔的摩，MD），一个三级和四级医疗中心，拥有全州范围的创伤转介中心以及骨科住院医师和研究员培训计划。
在研究期间在该机构的所有骨科住院医师和研究员。
学员未能记录其病例的时间为 24%（465/1925），其中住院医师为 25%（283/1117），研究员为 23%（182/808）（p=0.16）。在记录的病例中，CPT 代码漏记的时间为 46%（673/1460），额外代码添加的时间为 28%（412/1460），与主治医生相比。在调查中，大多数学员表示，他们“非常”或“非常”需要能够正确编码（83%；29/35）。
在这项对骨科学员病例记录实践的研究中，病例未记录的时间为 24%。由于准确性存在潜在问题，应谨慎对待依赖学员病例记录的活动。
