Time spent on clinical documentation: a survey of internal medicine residents and program directors

Abstract

Background: Clinical documentation and clerical duties are substantial activities for internal medicine residents. Therefore, we sought to understand the perspectives of internal medicine residents regarding the time devoted to documentation and direct patient care, as well as the perceived frequency and importance of feedback on patient-related documentation.

Methods: As part of the 2006 US Internal Medicine In-Training Examination, residents voluntarily completed a survey that included questions on the average daily hours spent in direct patient contact and clerical documentation during inpatient rotations. Residents and program directors were asked to report on the frequency and importance of feedback provided to trainees by faculty on patient-related documentation.

Results: A total of 16 402 trainees (85.9%) and 235 PDs (61.7%) completed the survey. There were 67.9% of residents who reported spending in excess of 4 hours daily on documentation; only 38.9% reported spending this amount of time in direct patient contact. The majority of residents (56.5%) and program directors (63.0%) believed that feedback on documentation occurred less than 50% of the time. Program directors were more likely than residents to view feedback on documentation as highly important (73.2% vs 58.6%; P < .001).

Conclusions: Internal medicine residents perceive that they are spending excessive time in the hospital setting on clerical documentation. Further evaluation to understand specific inpatient activities of residents and the educational value of those activities is essential.