Can you really infer that? An exploratory study using the reasoning task typology to analyze clinic notes

Area of Science:

• Medical Education
• Clinical Reasoning Assessment
• Health Informatics

Background:

• Assessing clinical reasoning is a core challenge in medical education.
• Written communication in clinical settings is a vital, multi-purpose educational tool.
• Existing methods often focus narrowly on cognitive aspects of clinical reasoning.

Purpose of the Study:

• To apply and validate a retrospective template analysis of clinical notes.
• To broaden the measurement of clinical reasoning using a comprehensive typology.
• To explore how written communication reflects clinical reasoning complexity.

Main Methods:

• Retrospective template analysis of clinical notes.
• Application of a comprehensive clinical reasoning typology.
• Analysis of factors influencing complexity, including coherence and ambiguity.

Main Results:

• Clinical reasoning assessment in notes is influenced by text coherence and semantic ambiguity.
• Significant clinical reasoning information is often inferred, not explicit.
• The structure of clinical narratives reflects physician-relative and cultural documentation practices.

Conclusions:

• Written clinical notes offer a rich, albeit complex, source for assessing clinical reasoning.
• Medical educators must teach explicit clinical reasoning explication in writing.
• The evolving electronic medical record and its technology shape clinical narratives and require pedagogical adaptation.