By Maria A. Colmer, OTD, OTR/L, Associate Professor, Academic Fieldwork Coordinator, Florida Gulf Coast University, OT Program, FLOTEC

How can Fieldwork Educators (FWEd) facilitate and assess students’ clinical reasoning skill development while on Level II Fieldwork? This article is not to teach FWEds how to reason but how to make their lives easier in terms of teaching and assessing students’ clinical reasoning.

Clinical reasoning and clinical decision making are often used synonymously but they are different. The reasoning (cognitive process) leads to clinical decisions. From the literature, several types of reasoning are outlined: narrative, interactive, collaborative, ethical, intuitive, examination, diagnostic, prognostic, intervention, and outcomes. Higgs and Jones (2008) define clinical reasoning as “an inferential process used by practitioners to collect and evaluate data and to make judgements about the diagnosis and management of patient problems.”

Clinical reasoning is embedded throughout the AOTA Fieldwork Performance Evaluation. To objectify clinical reasoning think in terms of six Lines of Thought – PEDPIO: Psychosocial, Examination, Diagnostic, Prognostic, Intervention, and Outcomes. Emphasize to students that clinical reasoning is ambiguous which makes assessing and facilitating a challenge. The intent of this discussion is to offer structure to clarify clinical reasoning and reduce ambiguity.

Models and algorithms are structures within which clinical reasoning is done and clinical decisions made. They are generally chronological and they outline client management. Clinical reasoning is to understand clients’ occupational needs and makes decision about the interventions. To simplify clinical reasoning FWEd can provide structure to minimize ambiguity and facility communication and student learning.

Clinical reasoning involves more than applying a theory. Complex clinical tasks often require the therapist to improvise a treatment approach to the client’s disability. The AOTA Practice Framework is one model used to provide structure to clinical reasoning (Evaluation, Intervention, and Outcomes). During the evaluation process we assess client’s occupational profile and analyze occupational performance. Intervention, we implement our plan and review the client’s abilities. Outcomes include: Occupational Performance, Prevention, Health and Wellness, Quality of Life, Participation, Role Competence, Well-being, and Occupational Justice.

Students often struggle verbalizing thoughts about clinical reasoning and FWEd sometimes have difficulties assessing students clinical reasoning skills. A good clinical reasoning homework assignment FWEd can offer students is to provide a case study and have the student apply the six Lines of Thought (PEDPIO). Make sure the six Lines of Thought correlate among each other like components of a SOAP note.

The student can outline some psychosocial issues a client may be experiencing, discuss some evaluation results, include some diagnostic and prognostic reasoning, outline an intervention to improve what the student presented in the evaluation results, and discuss outcomes.

After the FWEd presents the student with a case study the FWEd will ask the student Explain to me your thought about this client.

The student should respond: From a psychosocial perspective . . . what stood out most during the evaluation was . . . therefore I chose to examine . . . and the primary findings were . . . therefore I’m thinking we should focus on . . . for treatment.

During a discussion, a good practice to guide the student is to ask Why five times. The primary goal is mindful practice and keys to becoming mindful is to reflect, slow down and organize the student’s brain.


Higgs J, Jones M. Clinical decision making and multiple problem spaces. In: Higgs K. Jones MS, Lotfus S, Chrsitensein N. Clinical reasoning in health professions. Amsterdam: Elserier: 2008. p. 4-19.

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