SHORT-TERM AND LONG-TERM IMPACT OF DIDACTIC INSTRUCTION UPON MEDICOLEGAL QUALITY OF RADIATION ONCOLOGY RESIDENT PHYSICIAN DOCUMENTATION

Purpose:

Effective documentation is essential in medical practice, particularly in Radiation Oncology (RO), where interdisciplinary collaboration is key. While documentation guidelines exist, it is uncertain if RO residents are aware of or adhere to them. This study assessed RO residents’ medicolegal knowledge of clinical documentation and evaluated the short- and long-term impact of an educational intervention on documentation practices.

Materials and Methods:

Grading rubrics for consultation and progress notes were created using existing guidelines. Residents from two academic institutions attended a virtual didactic seminar on medicolegal documentation. An electronic anonymous survey assessed resident knowledge and perspectives, both pre- and post-seminar. Randomly selected consultation and progress notes completed before the seminar and during short-term (<3 months) and long-term (<18 months) intervals were evaluated using the rubrics. Descriptive statistics and T-tests were utilized to analyze the data.

Results:

14 residents participated and completed surveys, while 11 submitted documentation. None had prior education specific to RO documentation, nor were they aware of available resources. Post-seminar, participants’ understanding of documentation (2.79 versus 3.43, p=0.045), informed consent (2.71 versus 3.79, p=0.002), and knowledge testing quiz scores (86.6% versus 95.5%, p=0.001) increased. Clinically, sustained improvements were observed in consultation notes (69.8% versus 79.9% & 87.4%, p=0.001 & p<0.001; short-term and long-term respectively) and progress notes (55% versus 75.2% & 79.4%, p<0.001 & p<0.001; short-term and long-term respectively).

Conclusions:

Our seminar significantly enhanced residents’ medicolegal knowledge and documentation quality, with immediate and sustained effects. Additionally, surveys revealed a lack of specialty-specific documentation education. Given the observed improvements in knowledge and clinical documentation, integrating structured medicolegal training into residency curricula could help standardize documentation practices. Future studies could explore the sustained retention of these skills and assess the impact of continued reinforcement through periodic educational seminars.