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¿Realmente puedes inferir eso? Un estudio exploratorio que utiliza la tipología de tareas de razonamiento para

David Chartash^1,2, Jacqueline Torti³, Brandi E Stevens⁴

¹Department of Biomedical Informatics and Data Science, School of Medicine, Yale University, New Haven, CT, USA. david.chartash@yale.edu.

Advances in health sciences education : theory and practice

|December 12, 2025

Resumen

Este estudio muestra que el análisis de las notas clínicas puede evaluar el razonamiento clínico más allá de las habilidades cognitivas. La comunicación escrita médica a menudo implica conocimiento, lo que resalta la necesidad de enseñar el razonamiento clínico explícito en la documentación.

Área de la Ciencia:

Educación Médica
Evaluación del Razonamiento Clínico
Informática de la Salud

Sus antecedentes:

La evaluación del razonamiento clínico es un desafío central en la educación médica.
La comunicación escrita en entornos clínicos es una herramienta educativa vital y multipropósito.
Los métodos existentes a menudo se centran estrechamente en los aspectos cognitivos del razonamiento clínico.

Objetivo del estudio:

Aplicar y validar un análisis de plantilla retrospectivo de notas clínicas.
Ampliar la medición del razonamiento clínico utilizando una tipología integral.
Explorar cómo la comunicación escrita refleja la complejidad del razonamiento clínico.

Principales métodos:

Análisis de plantilla retrospectivo de notas clínicas.
Aplicación de una tipología integral de razonamiento clínico.
Análisis de factores que influyen en la complejidad, incluida la coherencia y la ambigüedad.

Principales resultados:

La evaluación del razonamiento clínico en las notas está influenciada por la coherencia del texto y la ambigüedad semántica.
La información significativa sobre el razonamiento clínico a menudo se infiere, no es explícita.
La estructura de las narrativas clínicas refleja prácticas de documentación relativas al médico y culturales.

Conclusiones:

Las notas clínicas escritas ofrecen una fuente rica, aunque compleja, para evaluar el razonamiento clínico.
Los educadores médicos deben enseñar la explicación explícita del razonamiento clínico por escrito.
El expediente médico electrónico en evolución y su tecnología dan forma a las narrativas clínicas y requieren adaptación pedagógica.

Palabras clave:

Documentación clínica Narrativa clínica Razonamiento clínico Educación médica de posgrado Pediatría

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