An Innovative Curriculum Using a Simulated Electronic Health Record to Teach Internal Medicine Residents About ICD–10-CM

Abstract

Introduction This module introduces learners to the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD–10-CM) coding system and its relevance to patient care, billing, and public health. Knowledge of this coding system is critical for residents about to enter independent practice. Methods This case was developed for internal medicine residents at all levels of training and was delivered in three 50-minute sessions. Associated materials include a test given before and after the module, the answer key to that test, the clinical case and associated learning objectives, a faculty guide, and an evaluation form. This module features a simulated patient encounter in an electronic health record, the details of which are given in the faculty guide. Results Eighty-eight percent of learners reported that they found this exercise useful, and there was a significant improvement in posttest scores after completion. Ninety-four percent of learners reported a commitment to using appropriate ICD–10-CM codes in their own practice after completion of the exercise. Discussion This effective module has been integrated into our ambulatory curriculum. Knowledge of ICD–10-CM coding allows physicians to document specifically and appropriately as they move forward in their practice.

Keywords

• Documentation
• Electronic Health Records
• ICD–10
• International Classification of Diseases
• Ambulatory Education