Using Chart Review and Chart-Stimulated Recall for Resident Assessment

The Challenge

Formative and summative assessment of residents' clinical reasoning, decision-making, and documentation skills is challenging, as it occurs “inside the learner's head.” Educators seek strategies to assess and provide feedback on this critical competency, and medical education researchers require clinically relevant measures of the educational impact of new curricula or other teaching innovations.^1–3 Assessments based on chart review (CR) or chart-stimulated recall (CSR) allow trainees to articulate their process of clinical decision-making and the underlying rationale to be articulated.

What Is Known

CR and CSR assess clinical competence using a clinician's documented patient encounter as the starting point for assessmentt of clinical reasoning and clinical documentation.^4,5 Patient records for CR and CSR are usually selected by faculty providing assessment, but may also be selected by the learner. CR focuses on trainees' medical record documentation. CSR adds an oral examination component—asking the trainee to externalize his or her thought processes—to elicit diagnostic reasoning, decision-making, and related decisions such as use of resources or communicating with patients, families, or other members of the health care team. CR-based feedback on diagnostic performance can motivate residents to improve their clinical reasoning.⁶ CSR scoring forms range from checklists with comment boxes to rating scales for a standardized assessment.⁵ CSR has been shown to provide valuable and useable feedback for trainees at varying levels, with value extending to marginally performing learners with limited clinical diagnostic and clinical reasoning skills to high-performing, advanced learners.^7,8 CSR can also be used to provide feedback on other competencies, such as communicating with patients and families, clinical documentation, and understanding systems of care. Using CSR for high-stakes assessments has been suggested, but must address issues common in all clinical performance assessments, including number and representativeness of cases selected and rater training/scoring.

How You Can Start TODAY

1. Determine if CR/CSR meets your needs. Discuss with your Clinical Competency Committee how CR and CSR may expand and enrich your assessment toolbox, and provide feedback to trainees relating to their patient care, clinical diagnosis and decision-making, communication, and documentation skills.

2. Use a CR/CSR worksheet to structure your review. Select the context (eg, a resident clinic session, patient consult, recently discharged patient, or selected contexts to assess and assist a learner in difficulty). Allocate 10 to 15 minutes for CR review and feedback, and 15 to 20 minutes for a CSR session. Highlight no more than 3 strengths and 3 areas for improvement per session. Use a self-guided worksheet for CR and CSR. See the box for a sample worksheet.

3. Use the CR worksheet section No. 1 to provide feedback on residents' clinical documentation in the electronic health record or a print out or paper chart. Highlight effective documentation practices.

What You Can Do LONG TERM

1. Teach senior residents how to use CR and CSR to provide “near-peer” feedback to junior learners, using “7 Principles of Good Feedback,” and mentor them in this new role.⁹

2. Modify the CSR form for specific settings and context, by deleting nonrelevant sections.

3. Identify potential possible barriers to CR and CSR posed by your electronic health record (eg, focus on billing, lack of reasoning process documentation), and how to overcome them.

4. Create electronic versions of the CR and CSR feedback forms as part of your assessment system.

5. Seek feedback from learners, faculty, and the Clinical Competency Committee about the utility of CSR and incorporate this into your assessment approach.

6. Use CR for program evaluation or as an outcome measure after curriculum change or other interventions.