Background: High quality clinical documentation is essential for patient safety. Thoughtful clinical documentation transmits one’s clinical reasoning and is considered to be a professional responsibility. There are no accepted standards for assessing documentation with respect to clinical reasoning. We therefore undertook this study to establish a metric to evaluate hospitalists’ documentation of clinical reasoning in [...]

Background: Written patient discharge instructions play an important role in patient education upon discharge from the hospital. Writing clear, concise instructions is documented to reduce re-admission rates. [1,2] Despite the importance of well-written discharge instructions, we found that medical students at our institution received little formal education in writing discharge instructions during their pre-clinical courses [...]