A Clinical Reasoning Workbook
Provided by the
The QSR Institute and Janus, LLC
Booklet with Jamie’s Situation, Directions, and Worksheets to Use for Classroom Practice:
•Overview of Clinical ReasoningSteps
•Jamie’s Situation for ClassroomPractice
•Example Bio-Psycho-Social AssessmentOrganizer
•Notes from Jamie’s Bio-Psycho-SocialAssessment
•Clinical Reasoning Worksheet (groupactivity)
•Case Formulation Worksheet (groupactivity)
•Case Planning Worksheet (groupactivity)
Page 1 • Developed by R. Foster/K. Gibbons in partnership with NM-BHSD, 2017
Clinical Reasoning in Practice
ProcessDescription
Describe the facts, context, circumstances, events, and people involved. Why is this person involved
Consider the Person’s Situationwiththeservicesystem?Whatarepeopleseekingfromservicesatthistime?Aretherightpeople
engaged, involved, and working together in planning services for the person?
Collect & Assemble Information / Review current information (e.g., intake summaries; person’s history; progress information; results of investigations, lab tests, medical exams, previous assessments, collateral reports, court orders)
Gather new information (e.g., undertake new assessments to identify the person’s functional strengths, major unmet needs, risk of things that could go wrong, underlying factors that drive the behavioral dynamics of concern)
Recall knowledge applicable to understanding the person’s situation (e.g., physiology, pharma- cology, epidemiology, treatments, culture, support system, ethics, law, etc.)
Process Information to Recognize Patterns, Build Understanding, Discern Solution Possibilities / Interpret: analyze data to develop an understanding of signs, symptoms, conditions, behaviors, life challenges, any current diagnoses, and consequences of recent lifestyle choices. What bio-psycho- social factors explain this person’s present situation and state of need?
Discriminate: distinguish relevant and irrelevant information information; recognize inconsistencies; narrow down the information to what is most important; recognize gaps, needs, risks, and opportuni- ties in cues collected.
Relate: discover new relationships or patterns; cluster cues together to identify relationships between them. Look for triggers of problem behaviors or health concerns. Recognize causes and effects.
Infer: make deductions and develop solution opinions that follow logically by interpreting the subjec- tive and objective cues; consider solution alternatives and consequences. What does this person need most right now to get better, do better, and stay better?
Match current situation to past situations or the current person to others previously served who presented similar problem patterns. Consider solution options and strategies most likely to work.
Define Outcomes Necessary and Select Strategies for Interventions / Describe relevant outcomes (desired conditions reflecting life changes) with specific measures that will indicate when the outcomes have been achieved. Life change outcomes usually relate to the person’s well-being (health, safety, stability), supports for living (housing, health care, income), daily functioning, and/or fulfillment of expected life roles (student, friend, parent, employee, tenant).
Discern outcome pathways (usually through an expert reasoning process). What things would have to change for this person to get better, do better, and stay better? What could go wrong in this person’s life (based on history and tendencies) and how to prevent those things in the future?
Plan & Take Action / Plan intervention strategies and actions that will lead to the attainment of the life change outcomes. Implement those actions, track response to interventions, make adjustments to find what works.
Evaluate Efforts & Results / Evaluate the effectiveness of actions and outcomes. Ask: Is the person doing better, getting better, and staying better? Has the situation that brought the person into services been improved?
Reflect on the Process &Contemplatewhatyouandothershavelearnedfromthisprocessandwhatyoucouldhavedone
What has been Learneddifferently.Whatworkedinthissituationandwhy?Howdoweapplynewlearningtothenextsteps
in this case? Next time I would... I should have... If I had... I now understand....
Page 2 • Developed by R. Foster/K. Gibbons in partnership with NM-BHSD, 2017
Clinical Reasoning:
A Practice Activity
Directions: Organize these facts to develop a working Clinical Formulation along with Outcomes and Intervention Strategies for Jamie.
Clinical Reasoning Practice Activity Continued
Jamie’s Situation Continued
EXAMPLE of a Bio-Psycho-Social AssessmentOrganizerDomains: Bio-psycho-social assessment organizer for noting factors that explain a person’s present situation and state of need.
Adapted from Barker, P. The child and adolescent psychiatry evaluation: basic child psychiatry. Oxford, UK: Blackwell Scientific, Inc.; 1995.
Page 4 • Developed by R. Foster/K. Gibbons in partnership with NM-BHSD, 2017
Practitioner’s Bio-Psycho-Social Assessment Notes for Jamie
Domains: Bio-psycho-social assessment organizer for explaining predisposing, precipitating, perpetuating, and protective factors in Jamie’s life situation.
Adapted from Barker, P. The child and adolescent psychiatry evaluation: basic child psychiatry. Oxford, UK: Blackwell Scientific, Inc.; 1995.
Page 5 • Developed by R. Foster/K. Gibbons in partnership with NM-BHSD, 2017
Clinical ReasoningBrief Description of Person’s Situation: Who is Jamie (age, gender, etc.)? What arethe
reasons that Jamie is involved in services?
Worksheet
1. People Involved: Who are the people involved in supporting and serving this person? How well are they engaged, involved, and committed to helping this person get better, do better, and stay better?
2. Expectations: What outcomes of intervention are people expecting to be achieved? The person? The parent/family, life partner, and/or key supporters? The school or employer? The court? Service providers?
3. Causal Explanations: What bio-psycho-social factors, life circumstances, and underlying issues explain the person’s presenting problem(s) and current needs? [See the Bio-Psycho-Social Assessment information provided on pages 3 and 5]
4. Risk Factors: Based on history and tendencies, what things could go wrong in this person’s life? What must be done to avoid or prevent future harm, pain, loss, or undue hardship?
5.FunctionalStrengthsAssets:Whataretheperson’sfunctionalstrengths,aspirationsforchange,andlifeassetsthatcanbebuiltuptosolvethe problem(s)thatbroughtthepersonintoservices?
6.CriticalUnmetNeeds:Whatpresentlyunmetneedswouldhavetobefulfilledinorderforthispersontogetbetter,dobetter,andstaybetter?
7.Change Targets: What things in the person’s life will have to change in order for the person to achieve adequate well-being, have essential supports for living, functionadequately,andfulfillkeyliferoles?
8.Life Change Outcomes: What conditions when met will show that the person’s problem(s) is/are solved (e.g., achieved adequate well-being, has supports for living, functions adequately, and fulfills key life roles)? [Use WorksheetProvided]
•Well-BeingOutcomes(e.g.,safety,health,stability,permanency):
•SupportsforLivingOutcomes(e.g.,housing,income,healthcare,childcare):
•DailyFunctioningOutcomes(e.g.,ADLs,self-direction,academictasks,socialization):
•RoleFulfillmentOutcomes(e.g.,friend,student,parent,career/employment):
9. Intervention Strategies: What combination and sequence of intervention strategies are likely to bring about desired life changes? [Use Worksheet Provided]
10. Finding What Works: How will people know: (1) That interventions are being delivered as planned and are working? (2) When should interventions be changed or stopped? (3) When life change outcomes have been achieved at a satisfactory level?
Page 6 • Developed by R. Foster/K. Gibbons in partnership with NM-BHSD, 2017
Page 7 • Developed by R. Foster/K. Gibbons in partnership with NM-BHSD, 2017
Case PlanningBrief Description of Person’s Situation: Who is Jamie? What are the reasons Jamieis
involved in services?
Worksheet
General Guidance: This worksheet is designed to organize intervention planning for a person receiving services. It links together the Life Change Outcomes
planned with and for the person, the Intervention Strategies that will be used to bring about life changes, and Actions planned to implement intervention strategies.
LOGIC OF APPROACH: The practitioner should first plan to meet any Compelling Urgencies requiring Immediate Action to prevent harm. After any such urgencies are addressed, focus next on any Life Outcomes related to Achieving Well-Being (e.g., safety, health, stability/permanency) and Life Outcomes related to Supports for Living (e.g., income, food, housing, health care). Once needs for well-being and supports for living are being met, the focus shifts to Life Outcomes related to adequate Daily Functioning and fulfilling Key Life Roles. This progression of meeting essential needs and strategic life changes should enable the person to achieve and maintain an adequate daily life situation and gain greater independence from the service system. When selecting from among near-term goals and strategies, the practitioner should give priority to any Ready Opportunities for getting early and repeated successful results. Likewise, Priority should be given any important life outcome that could be easily and readily achieved, leading to Early Victories in life change efforts.
ORDER AND PACE OF INTERVENTIONS: 1) Work from Urgent to Strategic; 2) Select Strategies having Ready Opportunities for Action; 3) Select Strategic Options that can achieve a Rapid Outcome; 4) Sustain Motivation for life change by Gaining Early and Repeated Successes; and, 5) Avoid a Scope and Pace of Action that would Overwhelm the Person’s Life Situation and could Cause Resistance and Loss of Motivation.
Outcome byPriority / InterventionStrategies / Planned Actions
Compelling Urgency: Prevent harm / Strategy Used to Achieve Outcome: / Steps/Tasks to Implement Strategy:
State the Outcome to be Achieved: / • / •
• / •
• / •
Early Success: Build confidence & motivation / Strategy Used to Achieve Outcome: / Steps/Tasks to Implement Strategy:
State the Outcome to be Achieved: / • / •
• / •
• / •
Rapid Completion: Achieve a key victory / Strategy Used to Achieve Outcome: / Steps/Tasks to Implement Strategy:
State the Outcome to be Achieved: / • / •
• / •
• / •
Capacity Building: Build long-term capacity / Strategy Used to Achieve Outcome: / Steps/Tasks to Implement Strategy:
State the Outcome to be Achieved: / • / •
• / •
• / •
Page 8 • Developed by R. Foster/K. Gibbons in partnership with NM-BHSD, 2017