Stroke clinical documentation education program in Australia and New Zealand

Abstract

Background: Accurate and complete clinical documentation underpins the assignment of International Classification of Disease codes used for epidemiological research, hospital activity based funding, and health service planning. Objective: To develop, implement, and evaluate an education program for clinicians and clinical documentation specialists (CDS) to improve clinical documentation of stroke. Method: An education program to improve clinical documentation of stroke was developed by the Australia and New Zealand Stroke Coding Working Group. Eligible participants were clinicians (doctors, nurses, and allied health) and CDS in Australia or New Zealand. The education program comprised 4 modules in a pre-recorded 10-minute educational video. Surveys were administered before and after the educational video to evaluate knowledge (Kirkpatrick level 2) and obtain feedback. Quantitative data were summarised using descriptive statistics. Open-text responses to the feedback survey were analysed using inductive thematic analysis. Results: Among 72 eligible participants, 41 (57%) completed the pre- and post-educational knowledge assessment surveys ( n = 35 clinicians, n = 6 CDS). Compared with the pre-education survey, the median number of correct responses significantly increased in the post-education survey (pre: 3 [interquartile range (IQR) 2–4]; post: 5 [IQR 4–5]; p < 0.001). Most respondents (>90%) were satisfied with the education program, stating it provided “practical and transferrable knowledge” and that the education was “quick, clear, concise.” Conclusion: Our education program was associated with an increased knowledge of appropriate clinical documentation of stroke. Ongoing monitoring of clinical coding and clinical documentation is required to ascertain whether the education of the participants translates to improved clinical coding of stroke. Implications for health information management practice: Accurate and complete clinical documentation directly impacts clinical coding, which in turn affects reimbursement, patient safety, and data quality for epidemiological research, resource allocation, and health policy decision-making.