Teaching clinical documentation to fellow physicians

Finding a lack of resources and tools that provide direction on clinical documentation for physicians, Joseph Cristiano, MD, assistant professor of general internal medicine at Wake Forest Baptist Health in Winston-Salem, North Carolina, set out to educate himself about the topic. He found that many seasoned colleagues were equally in the dark in regard to clinical documentation. Recognizing this as a learning opportunity, Cristiano began informally educating himself by reaching out to the business and compliance offices at Wake Forest, which led to other individuals within his institution with clinical documentation experience. Eventually, finding he had a good grasp on evaluation and management billing and office visit billing, he started teaching faculty throughout the institution. He did so in collaboration with the compliance office.

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