Development of a Clinical Reasoning Documentation Assessment Tool for Resident and Fellow Admission Notes: a Shared Mental Model for Feedback.
assessment
clinical reasoning
documentation
feedback
Journal
Journal of general internal medicine
ISSN: 1525-1497
Titre abrégé: J Gen Intern Med
Pays: United States
ID NLM: 8605834
Informations de publication
Date de publication:
02 2022
02 2022
Historique:
received:
10
11
2020
accepted:
03
04
2021
pubmed:
5
5
2021
medline:
12
3
2022
entrez:
4
5
2021
Statut:
ppublish
Résumé
Residents and fellows receive little feedback on their clinical reasoning documentation. Barriers include lack of a shared mental model and variability in the reliability and validity of existing assessment tools. Of the existing tools, the IDEA assessment tool includes a robust assessment of clinical reasoning documentation focusing on four elements (interpretive summary, differential diagnosis, explanation of reasoning for lead and alternative diagnoses) but lacks descriptive anchors threatening its reliability. Our goal was to develop a valid and reliable assessment tool for clinical reasoning documentation building off the IDEA assessment tool. The Revised-IDEA assessment tool was developed by four clinician educators through iterative review of admission notes written by medicine residents and fellows and subsequently piloted with additional faculty to ensure response process validity. A random sample of 252 notes from July 2014 to June 2017 written by 30 trainees across several chief complaints was rated. Three raters rated 20% of the notes to demonstrate internal structure validity. A quality cut-off score was determined using Hofstee standard setting. The Revised-IDEA assessment tool includes the same four domains as the IDEA assessment tool with more detailed descriptive prompts, new Likert scale anchors, and a score range of 0-10. Intraclass correlation was high for the notes rated by three raters, 0.84 (95% CI 0.74-0.90). Scores ≥6 were determined to demonstrate high-quality clinical reasoning documentation. Only 53% of notes (134/252) were high-quality. The Revised-IDEA assessment tool is reliable and easy to use for feedback on clinical reasoning documentation in resident and fellow admission notes with descriptive anchors that facilitate a shared mental model for feedback.
Sections du résumé
BACKGROUND
Residents and fellows receive little feedback on their clinical reasoning documentation. Barriers include lack of a shared mental model and variability in the reliability and validity of existing assessment tools. Of the existing tools, the IDEA assessment tool includes a robust assessment of clinical reasoning documentation focusing on four elements (interpretive summary, differential diagnosis, explanation of reasoning for lead and alternative diagnoses) but lacks descriptive anchors threatening its reliability.
OBJECTIVE
Our goal was to develop a valid and reliable assessment tool for clinical reasoning documentation building off the IDEA assessment tool.
DESIGN, PARTICIPANTS, AND MAIN MEASURES
The Revised-IDEA assessment tool was developed by four clinician educators through iterative review of admission notes written by medicine residents and fellows and subsequently piloted with additional faculty to ensure response process validity. A random sample of 252 notes from July 2014 to June 2017 written by 30 trainees across several chief complaints was rated. Three raters rated 20% of the notes to demonstrate internal structure validity. A quality cut-off score was determined using Hofstee standard setting.
KEY RESULTS
The Revised-IDEA assessment tool includes the same four domains as the IDEA assessment tool with more detailed descriptive prompts, new Likert scale anchors, and a score range of 0-10. Intraclass correlation was high for the notes rated by three raters, 0.84 (95% CI 0.74-0.90). Scores ≥6 were determined to demonstrate high-quality clinical reasoning documentation. Only 53% of notes (134/252) were high-quality.
CONCLUSIONS
The Revised-IDEA assessment tool is reliable and easy to use for feedback on clinical reasoning documentation in resident and fellow admission notes with descriptive anchors that facilitate a shared mental model for feedback.
Identifiants
pubmed: 33945113
doi: 10.1007/s11606-021-06805-6
pii: 10.1007/s11606-021-06805-6
pmc: PMC8858363
doi:
Types de publication
Journal Article
Research Support, Non-U.S. Gov't
Langues
eng
Sous-ensembles de citation
IM
Pagination
507-512Informations de copyright
© 2021. Society of General Internal Medicine.
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