Staff training · Acute care OT

Clinical Reasoning Sheet

One page for the clinical reasoning a therapist does during chart review, before entering the room, so they walk in knowing what to expect and what to watch for.

Audience
Acute care OTs, new staff
Setting
Acute care, trauma center
Format
One-page decision guide
Pairs with
Line Management, IRF vs. SNF card

The project

Problem

Acute care patients at a trauma center come with long histories, lines, precautions and changing vitals. Therapists new to the setting have a lot to track at once, and a missed precaution or vital sign can put a patient at risk.

Solution

A one-page guide for chart review: why the patient is here, history and home, consults, the diagnosis and the deficits to expect, and safety, with room to compare what was expected with what was seen.

How it's used

The therapist fills it in during chart review, before seeing the patient, to plan the session and flag safety concerns. Witnessed deficits and the discharge recommendation are added after the session.

The project · Clinical reasoning sheet

Sample patient

Acute clinical reasoning

Filled in for a made-up composite patient, the way a therapist would during chart review. No real patient information. On a phone, swipe sideways to see the whole sheet.

CLINICAL DECISION GUIDE

1
RM 412NAME J.D., 74 MCHIEF COMPLAINT: Fall at home, R hip pain
2
PMHX:HTN, DM2, A-fib on Eliquis, L CVA 2021 (no residual)
HOME:Lives w/ wife, 1-story, 3 STE w/ rail. Indep ADLs, cane outside
3
CONSULTS:Ortho, Cardiology, CM
4
DIAGNOSIS:R hip fx s/p ORIF, POD 1
ANTICIPATED DEFICITS:Pain, LB dressing, toileting, transfers, endurance
5
SAFETY
  • WBAT RLE · posterior hip precautions
  • High fall risk · bed alarm on
  • Foley · JP drain R hip · PIV L forearm
  • Eliquis held, watch for bleeding · Hgb 8.4 (was 11.2)
  • BP 102/58 this AM, check orthostatics before standing
6
WITNESSED  DEFICITS:Mod A sit-stand w/ RW, max A LB dressing, dizzy at 2 min
7
D/C RECOMMENDATIONS WITH JUSTIFICATION:IRF. Indep at baseline w/ wife at home to help.Now mod A transfers, max A LB ADLs. Hip fx is aqualifying dx. Tolerated 30 min w/ 1 rest break and ismotivated to return home. Needs daily OT/PT + MD oversightfor BP and Hgb.

How to read it

  1. 1

    Patient and chief complaint

    Room, name and why the patient came in, in one box across the top, so the reason for admission is the first thing the therapist reads.

  2. 2

    History and home

    Past medical history, then the home setup and prior level of function. Together they set the baseline the patient is working back toward.

  3. 3

    Consults

    Who else is involved in care, so the therapist knows who to call with a concern or a recommendation.

  4. 4

    Diagnosis and anticipated deficits

    The diagnosis, then the deficits it usually brings. Writing them down before entering the room gives the evaluation a focus.

  5. 5

    Safety

    The biggest box on the page, outlined in red: precautions, lines, drains, fall risk, vitals and anything from the chart that changes how the patient can move, noted before the therapist walks in.

  6. 6

    Witnessed deficits

    Added after the session: what the therapist actually saw. Comparing it with the anticipated deficits from chart review shows where the reasoning held up and what was missed.

  7. 7

    Discharge recommendation

    The recommendation with its justification, built from the witnessed deficits, ready to share at rounds and carry into the note.