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Although some skills of clinical reasoning can be assessed with the OSCE patient interview and physical examination, a post-encounter patient note and reflection affords the opportunity for the learner to demonstrate the ability to organize information gathered, synthesize and interpret data, and document a prioritized differential diagnosis and management plan. Clinical reasoning is a complex construct with multiple components including information gathering, hypothesis generation, forming a problem representation (a summary of the patient presentation using abstract terms, unified medical concepts, and semantic qualifiers), formulating and prioritizing a differential diagnosis with diagnostic justification, and finally, developing a management and treatment plan [1, 2, 3]. Assessment of clinical reasoning can be challenging, and a good assessment program should include multiple assessment methods, cover all components of the clinical reasoning process, and include assessments from both the simulated clinical environment and workplace-based setting [2, 3].

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Post-encounter Learning and Assessment of Clinical Reasoning: Patient Notes and Reflections

  • 章节

  • 发表日期：

    2025年

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  • Verity Schaye,
  • Ruth Crowe,
  • Christine Beltran,
  • Colleen Gillespie

摘要

Although some skills of clinical reasoning can be assessed with the OSCE patient interview and physical examination, a post-encounter patient note and reflection affords the opportunity for the learner to demonstrate the ability to organize information gathered, synthesize and interpret data, and document a prioritized differential diagnosis and management plan. Clinical reasoning is a complex construct with multiple components including information gathering, hypothesis generation, forming a problem representation (a summary of the patient presentation using abstract terms, unified medical concepts, and semantic qualifiers), formulating and prioritizing a differential diagnosis with diagnostic justification, and finally, developing a management and treatment plan [1, 2, 3]. Assessment of clinical reasoning can be challenging, and a good assessment program should include multiple assessment methods, cover all components of the clinical reasoning process, and include assessments from both the simulated clinical environment and workplace-based setting [2, 3].