Documentation education for surgery residents

Andrea Garcia, The University of Texas School of Public Health


Clear and concise medical records are necessary for documenting, assessing and improving quality of healthcare services. Accurate medical record documentation is also fundamental for billing and reimbursement. A thorough literature review revealed that residents do not receive adequate, beneficial education on medical record documentation and coding. This is concerning because healthcare service delivery and funding relies on the physicians ability to produce appropriate medical records which then get translated into ICD-9 and DRG codes for healthcare reimbursements. This proposal demonstrates the need to educate surgical residents on documentation by hypothesizing that (a) the improvement of medical record clarity and accuracy will result in increased coder analyst productivity and job satisfaction as well as, (b) ensuring fair and appropriate reimbursements.

Subject Area


Recommended Citation

Garcia, Andrea, "Documentation education for surgery residents" (2015). Texas Medical Center Dissertations (via ProQuest). AAI1597528.