Clinical Summary and Reasoning Format: A Tool for Clinical Practice and Medical Training

Patients' records are often bulky and unwieldy, necessitating the creation of summaries. A structured summary format adds the advantage of improved organization and easier retrieval of information. However, typical clinical summary formats do not document intermediate deductions linking symptomatology to diagnosis and to that extent fall short of tracking the cognition process of the clinician. The Clinical Summary and Reasoning Format of the Faculties of Paediatrics of the National Postgraduate Medical College of Nigeria and the West African College of Physicians was designed to track the clinical thought and reasoning processes of clinicians. It consists of two major sections. The first section is for documenting data from history, physical examination and early laboratory reports while the second section is for recording hierarchical deductions on the way to reaching various levels of diagnosis. Definitions and descriptions of the various components of the format are herein presented. The usefulness of the format for clinical practice, clinical training and assessment of trainees is discussed.