Documentation of Clinical Reasoning in Admission Notes of Hospitalists: Validation of the CRANAPL Assessment Rubric

Abstract

OBJECTIVE: To establish a metric for evaluating hospitalists’ documentation of clinical reasoning in admission notes. STUDY DESIGN: Retrospective study. SETTING: Admissions from 2014 to 2017 at three hospitals in Maryland. PARTICIPANTS: Hospitalist physicians. MEASUREMENTS: A subset of patients admitted with fever, syncope/dizziness, or abdominal pain were randomly selected. The nine-item Clinical Reasoning in Admission Note Assessment & Plan (CRANAPL) tool was developed to assess the comprehensiveness of clinical reasoning documented in the assessment and plans (A&Ps) of admission notes. Two authors scored all A&Ps by using this tool. A&Ps with global clinical reasoning and global readability/clarity measures were also scored. All data were deidentified prior to scoring. RESULTS: The 285 admission notes that were evaluated were authored by 120 hospitalists. The mean total CRANAPL score given by both raters was 6.4 (SD 2.2). The intraclass correlation measuring interrater reliability for the total CRANAPL score was 0.83 (95% CI, 0.76-0.87). Associations between the CRANAPL total score and global clinical reasoning score and global readability/clarity measures were statistically significant (P < .001). Notes from academic hospitals had higher CRANAPL scores (7.4 [SD 2.0] and 6.6 [SD 2.1]) than those from the community hospital (5.2 [SD 1.9]), P < .001. CONCLUSIONS: This study represents the first step to characterizing clinical reasoning documentation in hospital medicine. With some validity evidence established for the CRANAPL tool, it may be possible to assess the documentation of clinical reasoning by hospitalists.

Development of a Clinical Reasoning Documentation Assessment Tool for Resident and Fellow Admission Notes: a Shared Mental Model for Feedback

“…We believe this enhances the existing tool as the addition of the descriptive anchors creates a shared mental model for feedback on clinical reasoning documentation focused on residents and fellows. 11,[20][21][22] We demonstrated validity evidence for this rubric using Messick's framework, ultimately creating a rubric that was easy to use with minimal training of faculty, thus easily implementable. Additionally, we demonstrated good reliability with an intraclass correlation between raters of 0.84, which is higher than what was described with the original IDEA assessment tool and higher than what we experienced using the original IDEA assessment tool in the first round of the iterative process of development.…”

“…[12][13][14][15][16][17] There are several note rating instruments that have been validated to assess documentation quality such as QNOTE, PDQI-9, the RED checklist, the HAPA form, the P-HAPEE rubric, the IDEA assessment tool, and the CRANAPL assessment rubric. 8,11,[18][19][20][21][22] However, these note rating instruments possess varying degrees of detailed evaluation of clinical reasoning. Of these note rating instruments, the IDEA assessment tool developed by Baker et al includes a robust assessment of clinical reasoning documentation.…”

Diagnosis Documentation of Critically Ill Children at Admission to a PICU*

“…In our own PICU, we will start by relaying our findings to staff at local venues such as patient safety meetings, discussing cases involving opportunities to improve diagnosis documentation at our morbidity and mortality conference, and working with our institution’s clinical documentation program to ensure that expectations for documentation address both reimbursement goals and the need to communicate diagnoses effectively. Future strategies to improve diagnosis documentation may include teaching clinicians how to write organized and well-supported diagnosis narratives which acknowledge uncertainty and identify remaining unknowns (8), using dictation and transcribing technology judiciously to create concise but complete notes, implementing documentation reminders and templates (22), formally assessing the quality of clinical reasoning discerned from narrative notes (25), and implementing peer-to-peer audit and feedback regarding the clarity and utility of documentation (22).…”

Development and Validation of a Formative Assessment Tool for Nephrology Fellows' Clinical Reasoning

“…Furthermore, we were able to model the instrument on the basis of several previously validated instruments that assess reasoning through written notes (interpretative summary, differential diagnosis, explanation of reasoning, and alternatives, Clinical Reasoning in Admission Note Assessment and Plan, and Diagnostic Justification). [22][23][24] The simulated encounter was accessed via a website created with WordPress and hosted by Temple University (https://sites.temple.edu/rene/case-2/; not publicly searchable). It included a 2-minute video of a standardized patient in an emergency department describing the history of her present illness with text captions.…”