Academic Journal
Can you really infer that? An exploratory study using the reasoning task typology to analyze clinic notes.
| Τίτλος: | Can you really infer that? An exploratory study using the reasoning task typology to analyze clinic notes. |
|---|---|
| Συγγραφείς: | Chartash D; Department of Biomedical Informatics and Data Science, School of Medicine, Yale University, New Haven, CT, USA. david.chartash@yale.edu.; School of Medicine, University College Dublin - National University of Ireland, Dublin, Co. Dublin, Ireland. david.chartash@yale.edu., Torti J; Center for Education Research & Innovation, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, ON, Canada., Stevens BE; Section of Pediatric Rheumatology, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA., Ferguson I; Section of Pediatric Rheumatology, Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA., Rosenman MB; Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA.; Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA., Brandt C; Department of Biomedical Informatics and Data Science, School of Medicine, Yale University, New Haven, CT, USA., Goldszmidt M; Center for Education Research & Innovation, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, ON, Canada. |
| Πηγή: | Advances in health sciences education : theory and practice [Adv Health Sci Educ Theory Pract] 2026 Sep; Vol. 31 (4), pp. 1127-1152. Date of Electronic Publication: 2025 Dec 12. |
| Τύπος έκδοσης: | Journal Article |
| Γλώσσα: | English |
| Στοιχεία περιοδικού: | Publisher: Springer Netherlands Country of Publication: Netherlands NLM ID: 9612021 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 1573-1677 (Electronic) Linking ISSN: 13824996 NLM ISO Abbreviation: Adv Health Sci Educ Theory Pract Subsets: MEDLINE |
| Imprint Name(s): | Publication: <2009- > : [Dordrecht] : Springer Netherlands Original Publication: Dordrecht ; Boston : Kluwer Academic Publishers, c1996- |
| Ιατρικοί όροι (MeSH): | Clinical Reasoning*, Humans ; Retrospective Studies ; Writing ; Communication ; Electronic Health Records ; Clinical Competence ; Narration |
| Περίληψη: | 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. (© 2025. The Author(s), under exclusive licence to Springer Nature B.V.) |
| Competing Interests: | Declarations. Ethical approval: This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Institutional Review Board approvals were obtained from Yale University Human Research Protection Program (HIC #2000023864). Consent to Participate declaration: not applicable. Competing interests: BES and IF treated the patients and wrote the notes which were used as data, and as such can be described as having a conflict of interest mediated by the methodology by which this analysis was conducted. |
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| Contributed Indexing: | Keywords: Clinical documentation; Clinical narrative; Clinical reasoning; Graduate medical education; Pediatrics |
| Entry Date(s): | Date Created: 20251212 Date Completed: 20260908 Latest Revision: 20260908 |
| Update Code: | 20260909 |
| DOI: | 10.1007/s10459-025-10493-w |
| PMID: | 41385004 |
| Βάση Δεδομένων: | MEDLINE |
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