Resident-Led Clinical Documentation Improvement in Cardiology
- 1Department of Internal Medicine, Guthrie/Robert Packer Hospital, Sayre, Pennsylvania, USA
Abstract
Background: Risk-adjusted quality metrics, including the mortality index and length of stay index, are central to evaluating cardiovascular care, yet documentation gaps can misrepresent institutional performance.
Project Rationale: At our rural academic medical center, the Cardiology service line demonstrated a baseline mortality index of 1.40, indicating 40% higher-than-expected mortality. We identified documentation gaps in common cardiology diagnoses as contributing factors.
Project Summary: This quality improvement study, with a retrospective preintervention comparison, analyzed 2,143 Cardiology encounters over 18 months (July 2024-December 2025). A resident-led intervention including resident training, peer review, and clinical documentation improvement specialist collaboration was associated with mortality index improvement from 1.40 to 0.97 (30.7% relative improvement) and length of stay index improvement from 0.91 to 0.85 (6.6%).
Take-Home Messages: A resident-led clinical documentation improvement initiative improved documentation accuracy of patient risk, increasing expected values and correcting artificially elevated quality indices without changing clinical care or actual patient outcomes.
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BibTeX
@article{raut2026residentled,
title = {{Resident-Led Clinical Documentation Improvement in Cardiology}},
author = {Akshay Raut and Shubhendu Bajpai and John Pamula},
journal = {JACC Case Reports},
year = {2026},
month = sep,
doi = {10.1016/j.jaccas.2026.109869},
url = {https://doi.org/10.1016/j.jaccas.2026.109869},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Resident-Led Clinical Documentation Improvement in Cardiology
AU - Akshay Raut
AU - Shubhendu Bajpai
AU - John Pamula
PY - 2026
DA - 2026/09/16
JO - JACC Case Reports
DO - 10.1016/j.jaccas.2026.109869
UR - https://doi.org/10.1016/j.jaccas.2026.109869
AB - Background: Risk-adjusted quality metrics, including the mortality index and length of stay index, are central to evaluating cardiovascular care, yet documentation gaps can misrepresent institutional performance. Project Rationale: At our rural academic medical center, the Cardiology service line demonstrated a baseline mortality index of 1.40, indicating 40% higher-than-expected mortality. We identified documentation gaps in common cardiology diagnoses as contributing factors. Project Summary: This quality improvement study, with a retrospective preintervention comparison, analyzed 2,143 Cardiology encounters over 18 months (July 2024-December 2025). A resident-led intervention including resident training, peer review, and clinical documentation improvement specialist collaboration was associated with mortality index improvement from 1.40 to 0.97 (30.7% relative improvement) and length of stay index improvement from 0.91 to 0.85 (6.6%). Take-Home Messages: A resident-led clinical documentation improvement initiative improved documentation accuracy of patient risk, increasing expected values and correcting artificially elevated quality indices without changing clinical care or actual patient outcomes.
SN - 2666-0849
ER -