Case Assignment: Clinical Reasoning Process

Case Assignment: Clinical Reasoning Process

Case Assignment: Clinical Reasoning Process

Case Assignment: Clinical Reasoning Process

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Week 1: Clinical Reasoning and the Physical Assessment Using course materials, textbooks, and the SOAP Note Format document provided in the Course Resources area of the course, choose a friend, colleague, or family member and perform a complete history on your “patient” that presents for a history and physical examination. This is the kind of history you might obtain from a new patient, or during an annual well-visit exam. You should devise a chief complaint so that you may document the OLDCART (HPI) data. You must use the chief complaint of fatigue, fever, and muscles aches. You should include a complete ROS and all the other components of a complete patient history. This week you will only need to document thesubjective portion of the SOAP note (not objective). Document your findings in a systematic manner and identify some of the key components of the history that may tip you off to primary care interventions that this patient may require. Share these findings in this discussion. Please note the first post is due by Tuesday, 11:59 p.m. MT.
Clinical reasoning, also known as clinical judgment, is the process by which clinicians collect signs, process information, understand the patient’s medical situation or problem, plan and implement appropriate medical interventions, evaluate outcomes, and learn from this entire process. In a nutshell, medical professionals use clinical reasoning to consider the various aspects of patient careand make a relevant and appropriate decision aimed at prevention, diagnosis, and treatment of a patient’s problem: a critical aspect of strong clinical skills and quality care.

The clinical reasoning process comprises eight main phases. This process is dynamic and hence the distinction between these phases is not remarkable. A superficial breakdown of the process is as follows:

  • Observe: Carefully observing the patient and his or her symptoms, and listing the facts.
  • Collect: Collecting detailed information, including both past and present facts related to the patient’s health and current medical situation or problem.
  • Process: Examining or processing the collected information to determine the best possible treatment plan.
  • Decide: Deciding the most appropriate treatment option for diagnosis, treatment, or prevention based on the in-depth analysis of patient’s history and current situation.
  • Plan: Creating a detailed treatment plan, which may require consulting with associate medical professionals or experts.
  • Act: Delivering the determined treatment plan efficiently and accurately.
  • Evaluate: Evaluating the treatment plan’s outcomes to gauge its effectiveness.
  • Reflect: Reflecting on the outcomes and determining whether the treatment plan should be altered or recorded for future reference.
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