你真的可以这样推断吗? 使用推理任务类型学的探索性研究来分析临床笔记
David Chartash1,2, 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
概括
这项研究表明,分析临床笔记可以评估超出认知能力的临床推理. 书面医学沟通往往意味着知识,强调需要在文档中教导明确的临床推理.
科学领域:
- 医学教育 医学教育
- 临床推理评估评估
- 医疗信息学 医疗信息学
背景情况:
- 评估临床推理是医学教育的一个核心挑战.
- 在临床环境中,书面沟通是一种至关重要的,多用途的教育工具.
- 现有的方法往往只关注临床推理的认知方面.
研究的目的:
- 应用和验证临床笔记的回顾性模板分析.
- 为了扩大临床推理的测量,使用全面的类型学.
- 探索书面沟通如何反映临床推理的复杂性.
主要方法:
- 临床笔记的回顾性模板分析.
- 应用一个全面的临床推理类型学.
- 分析影响复杂性的因素,包括连贯性和模糊性.
主要成果:
- 笔记中的临床推理评估受文本连贯性和语义模两可的影响.
- 重要的临床推理信息通常是推断的,而不是明确的.
- 临床叙述的结构反映了医生相对和文化记录实践.
结论:
- 书面临床笔记为评估临床推理提供了丰富而复杂的来源.
- 医学教育工作者必须以书面形式教导明确的临床推理解释.
- 不断发展的电子病历及其技术塑造了临床叙述,需要教学适应.
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