Mattingly & Flemming (1994) refer to clinical reasoning as the process used by practitioners to plan, direct, perform, and reflect on client care. Whenever one is engaged in thinking about, doing or planning occupational therapy services, he or she is involved in the clinical reasoning process. Clinical reasoning refers to the relationship that exists between formal theory and actual practice. It involves a total body process that uses our senses to help make clinical decisions. Flemming refers to this as “knowing more than we can tell.” This is referred to as tacit knowledge. It is the practical knowledge, the common sense knowledge or the intuitive knowledge that binds the theoretical components to the “doing” aspect of treatment (Mattingly & Flemming, 1994).
- Select and utilize standardized and non-standardized screening and evaluation tools. Incorporate information received from clients, family, consultants, other health professional and occupational therapy assistants to develop a treat plan focused on occupation.
- Interpret and apply models of practice and frames of reference resulting in evaluation and intervention supporting occupation-based outcomes.
- Develop intervention plans that reflect evidence-based and best practice guidelines that are safe and effective.
- Adapt assessment and treatment interventions to the context of clinical practice and unique client needs that supports occupational therapy assistant involvement when appropriate
- Develop clinical documentation that reflects the above objectives, demonstrates professional value and awareness of federal, state and facility standards, policies and laws. This includes supervision and coordination of the occupational therapy assistant documentation.