Background: Complete and accurate clinical documentation is essential for the assignment of ICD-10-AM codes used for epidemiological research, funding allocation and health service planning.
Aims: To determine the feasibility and effectiveness of an education program for clinicians to improve knowledge of stroke clinical documentation in Australia and New Zealand.
Methods: The Australia and New Zealand Stroke Coding Working Group co-developed a 17-minute pre-recorded clinical documentation education program presented by a neurologist. Content included: importance of accurate stroke documentation; link between documentation and clinical coding; tips to improve documentation. Clinicians at one Australian hospital and university were recruited for the pilot project. Pre- and post-education surveys were administered to assess knowledge of stroke documentation, and to obtain feedback. Descriptive analyses were used for quantitative data, and open-text comments were summarised thematically.
Results: Eight participants completed surveys. Respondents improved knowledge for 4/5 questions including the most important inclusions in clinical documentation, and the case study. Majority of respondents agreed that the content was pitched at an appropriate level, that the presenter had adequate knowledge and would recommend the session to colleagues. Respondents perceived the examples as beneficial, and enjoyed learning about the importance of clinical coding. Suggested improvements included providing more examples, and creating an additional resource to remember the key points.
Conclusion: This education program is feasible and effective to improve knowledge of stroke clinical documentation. The program has been updated to incorporate feedback and is currently being evaluated in a larger cohort. Final results will be presented at the conference.