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Chapter Objectives

Upon completion of this chapter, the learner should be able to:

  1. Discuss the steps associated with making clinical decisions.

  2. Analyze and interpret patient data using a patient management model to make sound clinical decisions.

  3. Design appropriate goals and objectives based on specific patient data.

Introduction

As more people across the country have direct access to rehabilitation services, therapists are becoming a frequent point of entry into the health-care system for patients with neurological disorders. The responsibility of autonomous practice means that, today more than ever, physical therapists (PTs) and occupational therapists (OTs) must be prepared to make sound clinical decisions including independently determining appropriate examination, evaluation, diagnosis, plan of care (POC), specific interventions, and appropriate referral. The processes involved in clinical decision-making are complex and include aspects of clinical reasoning, judgment, and problem-solving. In addition to these cognitive processes, decision-making requires a therapist to possess the discipline-specific knowledge and skills needed to manage the range of problems seen in patients with neurological conditions. Of course, the patient also plays an important role in this process as discussed in Chapter 1; indeed, it is the patient’s goals and values that establish the context for how a therapist gathers the information needed to develop the best plan for patient management. As a therapist gains practical experience, the ability to recognize similarities and differences between patients’ problems and diagnoses is also incorporated into the decision-making process. Thus, decision-making by therapists is a multidimensional, patient-centered process based on a therapist’s ability to use both discipline-specific and practical knowledge to weigh, prioritize, and draw conclusions about a patient’s functional problems. While Chapter 1 covered the principles and foundations that underlie effective clinical decisions, this chapter will explore the overall process and specific steps involved in making sound clinical decisions.

Elements of Clinical Decision-Making

While Chapter 1 described the foundations and principles of making clinical decisions, this chapter will describe the process of making clinical decisions. How does the PT or OT make sound clinical decisions? Before this question can be answered, one must understand the elements that contribute to clinical decision-making. Clinical reasoning is one element of clinical decision-making that has been described by Benamy (1996) as a cognitive process that guides the ongoing acquisition, recall, sorting, and prioritizing of information regarding the clinical situation. This process enables the therapist to draw conclusions and make the judgments and decisions that lead to the POC and outcomes assessment. The resulting decisions also contribute to modification of intervention plans that occur from the time a therapist first sees a patient until the patient is discharged from services, in one episode of care. Clinical reasoning is not outwardly visible to observers. It is an ongoing process and the basis for the decision-making that takes place at every point in the patient management process. Patient management is the ongoing decision process that ...

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