Documentation of Clinical Reasoning in Admission Notes of Hospitalists: Validation of the CRANAPL Assessment Rubric
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 (standard devision [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.
© 2019 Society of Hospital Medicine
Approximately 60,000 hospitalists were working in the United States in 2018.1 Hospitalist groups work collaboratively because of the shiftwork required for 24/7 patient coverage, and first-rate clinical documentation is essential for quality care.2 Thoughtful clinical documentation not only transmits one provider’s clinical reasoning to other providers but is a professional responsibility.3 Hospitalists spend two-thirds of their time in indirect patient-care activities and approximately one quarter of their time on documentation in electronic health records (EHRs).4 Despite documentation occupying a substantial portion of the clinician’s time, published literature on the best practices for the documentation of clinical reasoning in hospital medicine or its assessment remains scant.5-7
Clinical reasoning involves establishing a diagnosis and developing a therapeutic plan that fits the unique circumstances and needs of the patient.8 Inpatient providers who admit patients to the hospital end the admission note with their assessment and plan (A&P) after reflecting about a patient’s presenting illness. The A&P generally represents the interpretations, deductions, and clinical reasoning of the inpatient providers; this is the section of the note that fellow physicians concentrate on over others.9 The documentation of clinical reasoning in the A&P allows for many to consider how the recorded interpretations relate to their own elucidations resulting in distributed cognition.10
Disorganized documentation can contribute to cognitive overload and impede thoughtful consideration about the clinical presentation.3 The assessment of clinical documentation may translate into reduced medical errors and improved note quality.11,12 Studies that have formally evaluated the documentation of clinical reasoning have focused exclusively on medical students.13-15 The nonexistence of a detailed rubric for evaluating clinical reasoning in the A&Ps of hospitalists represents a missed opportunity for evaluating
METHODS
Study Design, Setting, and Subjects
This was a retrospective study that reviewed the admission notes of hospitalists for patients admitted over the period of January 2014 and October 2017 at three hospitals in Maryland. One is a community hospital (Hospital A) and two are academic medical centers (Hospital B and Hospital C). Even though these three hospitals are part of one health system, they have distinct cultures and leadership, serve different populations, and are staffed by different provider teams.
