Documenting resident procedure and diagnostic experience: simplifying the process.

BACKGROUND AND OBJECTIVES

The Residency Review Committee (RRC) requires documentation of family practice residents' procedural and diagnostic experiences. Further, hospital privileging is frequently based on documentation of prior clinical experience. Residency programs need a user-friendly (ie, resident-friendly) mechanism for collecting data and generating reports to document these experiences. This paper outlines a simplified, user-friendly method of documenting resident procedural and diagnostic experiences.

METHODS

We developed a pocket-sized, optically scannable card for data input. This is coupled with a computerized database with report generation capability. The system is based on diagnostic clusters to further simplify the data input process.

RESULTS

The system's setup costs are about $10,000. Annual maintenance and operational fees are about $5,000. After instituting the system, the number of residents submitting documentation information increased substantially.

CONCLUSIONS

This system meets both RRC and potential clinical privileging requirements and provides a useful tool for guiding resident evaluation and developing appropriate training opportunities during the latter half of the residency. Simplified, accurate documentation may allow for comparisons among residents at various levels--program, state, and national.