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

Abstract

Assessing clinical reasoning is a challenge in all stages of medical education. Beyond the verbal communication of clinical reasoning within the hierarchy of medical education, written communication is a multi-purpose complex adjunct to support the educational process. This study applied and validated a retrospective template analysis of clinical notes using a comprehensive clinical reasoning typology intended to broaden the measurement of clinical reasoning beyond predominantly cognitive activities. Applying the typology to written communication demonstrates that increasing complexity of the analysis is mediated by intra-textual and discourse coherence, as well as the semantic ambiguity of clinical writing. The findings from this study suggest that a significant amount of information during the clinical encounter is pertinent to clinical reasoning but inferred within the contextual medical knowledge held by the writing and reading physician. Ultimately the structure and purpose of the clinical narrative reinforces both a physician-relative and culturally shaped practice of documentation. Beyond specific findings from this study, as the electronic medical record further matures and is shaped by both technology and the computer itself in the exam room, educators must seek to teach the task of clinical reasoning explication through writing, yet pay attention to the technology within the encounter and medical record itself, which shapes the clinical narrative.