A practical self-assessment for GME, residency program, and compliance leaders.
Use this checklist to quickly gauge how prepared your residents are for real-world documentation and coding expectations—both during training and after graduation.
 

Foundational Training 

☐ Residents receive formal documentation education, not just ad hoc guidance
☐ Training is progressive by PGY level, not “one-and-done”
☐ Education aligns with current payer and regulatory expectations
☐ Documentation education goes beyond “compliance” and addresses clinical reasoning and decision-making

Curriculum & Delivery 

☐ Documentation education is standardized across programs or specialties
☐ Content is on-demand and accessible outside of live lectures
☐ Training fits within resident schedules without relying solely on protected didactic time
☐ Residents can revisit material as expectations increase year over year

Feedback & Skill Development 

☐ Residents receive specific feedback on documentation quality—not just corrections
☐ Faculty and attendings are aligned on what “good documentation” looks like
☐ Documentation feedback improves over time (not the same issues every year)
☐ Residents understand why documentation matters, not just what to document

Operational Impact 

☐ Poor documentation is not routinely delaying billing or causing rework
☐ Coding or compliance teams are not functioning as de facto educators
☐ Documentation issues are addressed upstream, not after claims are submitted
☐ There is visibility into common documentation gaps by training level

Readiness for Practice

☐ Graduating residents are prepared to document independently
☐ New attendings do not require extensive “re-training” after residency
☐ Documentation habits formed in training translate to financial and compliance stability
☐ Leadership is confident residents understand documentation expectations across care settings

Quick Scoring Guide 

• 0–6 checked → High risk: documentation education is largely informal or reactive
• 7–12 checked → Moderate risk: some structure exists, but gaps remain
• 13+ checked → Strong foundation with opportunities to refine and scale

If this checklist raised questions or highlighted gaps, you’re not alone—many programs recognize the need but lack a scalable, resident-focused solution.

 

 

Published: 02/11/2026

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