The diagnostic certainty levels of junior clinicians: A retrospective cohort study

ABSTRACT Purpose of the Study To characterise the documentation of working diagnoses and their associated level of certainty by clinicians assessing patients referred to the medical team from the emergency department. Design This was a single centre retrospective cohort study of non-consultant grade clinicians at the Royal London Hospital, Barts Health NHS Trust between 01/03/19 to 31/03/19. De-identified electronic health record data was collected to include the type of diagnosis documented (clinical, laboratory result or symptom/sign defined) and the certainty adjective used for single diagnoses. Presence or absence of diagnostic uncertainty was collected for multiple diagnoses. Results 865 medical assessments were recorded during the study period. 850 were available for further analysis. 420 presented a single diagnosis while 430 presented multiple diagnoses. Of the 420 single diagnoses, 67 (16%) were documented as either a symptom or physical sign, and 16 (4%) were laboratory-result defined diagnoses. No uncertainty was expressed in 309 (74%) of the diagnoses. Of 430 multiple diagnoses, uncertainty was expressed in 346 (80%) compared to 84 (20%) in which no uncertainty was expressed. Conclusion The documentation of working diagnoses is highly variable amongst non-consultant grade clinicians assessing patients admitted via the emergency department. In nearly three quarters of assessments with single diagnoses, no element of uncertainty was implied or quantified. More uncertainty was expressed in multiple diagnoses than single diagnoses however documentation style was heterogenous. These data have implications for prospective studies examining the quantification of diagnostic certainty and its association with important process or outcome measures.