When Reasoning Hurts: Source-Aware Evaluation of Frontier LLMs for Clinical SOAP Note Generation

Evaluating large language models (LLMs) for clinical documentation tasks such as SOAP note generation remains challenging. Unlike standard summarization, these tasks require clinical abstraction, normalization of colloquial language, and medically grounded inference. However, prevailing evaluation methods including automated metrics and LLM as judge frameworks rely on lexical faithfulness, often labeling any information not explicitly present in the transcript as hallucination. We show that such approaches systematically misclassify clinically valid outputs as errors, inflating hallucination rates and distorting model assessment. Our analysis reveals that many flagged hallucinations correspond to legitimate clinical transformations, including synonym mapping, abstraction of examination findings, diagnostic inference, and guideline consistent care planning. By aligning evaluation criteria with clinical reasoning through calibrated prompting and retrieval grounded in medical ontologies we observe a significant shift in outcomes. Under a lexical evaluation regime, the mean hallucination rate is 35%, heavily penalizing valid reasoning. With inference aware evaluation, this drops to 9%, with remaining cases reflecting genuine safety concerns. These findings suggest that current evaluation practices over penalize valid clinical reasoning and may measure artifacts of evaluation design rather than true errors, underscoring the need for clinically informed evaluation in high context domains like medicine.

AI-generated answers in high-stakes domains are often fluent but difficult to verify, especially when they contain multi-step reasoning rather than a single final answer. We propose a reasoning-based, reference-free framework for auditing LLM-generated outputs. The method decomposes a generated reasoning trace into segments, labels local premise-target relations using Natural Language Inference (NLI), and organizes these relations into a hypergraph. A deterministic backward AND-OR search then assigns segment-level audit labels that indicate how each segment is grounded within the generated response. We evaluate the framework in two settings: deductive mathematical reasoning with Hard2Verify, and open-ended medical reasoning with UroReason, a new physician-annotated benchmark of LLM reasoning traces from real clinical cases. Across these settings, our NLI-hypergraph audit provides a more reliable reference-free evaluation signal than direct LLM-as-judge baselines. In the clinical setting, state-of-the-art LLM judges often fail to identify problematic reasoning segments, over-accepting fluent but weakly grounded responses. Our results show that QA evaluation should account for how inferential relations compose across a reasoning trace, rather than relying only on final answers or LLMs as verifiers. UroReason will be made available through an API, and our code will be released as open source.

Across medical specialties, clinical practice is anchored in evidence-based guidelines that codify best studied diagnostic and treatment pathways. These pathways routinely fall short for the long tail of real-world care not covered by guidelines. Most medical large language models (LLMs), however, are trained to encode common, guideline-focused medical knowledge in their parameters. Current evaluations test models primarily on recalling and reasoning with this memorized content, often in multiple-choice settings. Given the fundamental importance of evidence-based reasoning in medicine, it is neither feasible nor reliable to depend on memorization in practice. To address this gap, we introduce OGCaReBench, a free-form retrieval-focused benchmark aimed at evaluating LLMs at answering clinical questions that require going beyond typical guidelines. Extracted from published medical case reports and validated by medical experts, OGCaReBench contains long-form clinical questions requiring free-text answers, providing a systematic framework for assessing open-ended medical reasoning in rare, case-based scenarios. Our experiments reveal that even the best-performing baseline (GPT-5.2) correctly answers only 56% of our benchmark with specialized models only reaching 42%. Augmenting models with retrieved medical articles improves this performance to up to 82% (using GPT-5.2) highlighting the importance of evidence-grounding for real-world medical reasoning tasks. This work thus establishes a foundation for benchmarking and advancing both general-purpose and medical LLMs to produce reliable answers in challenging clinical contexts.