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INTRODUCTION

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LEARNING OBJECTIVES

  1. Define clinical reasoning and identify factors that affect clinical decision making.

  2. Describe the key steps in the patient/client management process.

  3. Define the major responsibilities of the physical therapist in planning effective treatments.

  4. Identify potential problems that could adversely affect the physical therapist's clinical reasoning.

  5. Discuss strategies to ensure patient participation in the plan of care (POC).

  6. Identify key elements of physical therapy documentation.

  7. Differentiate between the clinical decision making approaches used by the expert versus novice physical therapist.

  8. Discuss the importance of evidence-based practice in developing the POC.

  9. Analyze and interpret patient/client data, formulate realistic goals and outcomes, and develop a POC when presented with a clinical case study.

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CLINICAL REASONING/CLINICAL DECISION MAKING

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Clinical reasoning is a multidimensional process that involves a wide range of cognitive skills physical therapists use to process information, reach decisions, and determine actions. Reasoning can be viewed as an internal dialogue that therapists continuously employ while meeting the challenges of clinical practice. Clinical decisions are the outcomes of the clinical reasoning process and form the basis of patient/client management. A number of factors influence decision making, including the clinician's goals, values and beliefs, psychosocial skills, knowledge base and expertise, problem-solving strategies, and procedural skills. Many of these factors are the focus of discussion in later chapters in this text. Decision making is also influenced by patient/client characteristics (goals, values and beliefs, and physical, psychosocial, educational, and cultural factors) as well as environmental factors (clinical practice environment, overall resources, time, level of financial support, level of social support).

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Decision making frameworks, such as algorithms, have been developed by experienced practitioners to guide clinicians in their reasoning processes. For example, Rothstein and Echternach developed the Hypothesis-Oriented Algorithm for Clinicians II (HOAC).1 An algorithm is a graphically represented step-by-step guide designed to assist clinicians in problem solving by considering several possible solutions. It is based on specific clinical problems and identifies the decision steps and possible choices for remediation of a problem. A series of questions are posed, typically in yes/no format, addressing whether the measurements met testing criteria, the hypotheses generated were viable, goals were met, strategies were appropriate, and tactics were implemented correctly.

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Hypotheses are defined as the underlying reasons for the patient's problems, representing the therapist's conjecture as to the cause. Problems are defined in terms of activity limitations. A "no" response to any of the questions posed in an algorithm is an indication for reevaluation of the viability of the hypotheses generated and reconsideration of the decisions made. In using HOAC II as a model for clinical decision making, the therapist also distinguishes between existing problems and anticipated problems, defined as deficits that are likely to occur if an intervention is not used for prevention. The value of an algorithm is that it guides the therapist's decisions and provides an outline of the decisions made. See Chapter 17, Figures ...

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