APPENDIX 2: Components of Clinical Decision Making

AHS (Alberta Health Services, 2017a) states there are ten consistent elements essential to clinical decision making across rehabilitation disciplines. These components are embedded in each of the four aspects of moving knowledge to action.  They were determined based on a collation of regulatory guidelines, AHS guidelines and clinical input.  Dynamic integration of all elements based on critical thinking and collaboration is required.  They are as follows:

    1. Screening: Critical clinical appraisal of available initial information to identify individual, family and community needs.
    2. Consent: Obtain informed consent to assess, treat, or disclose information.
    3. Assessment: Get to know the patient through critical inquiry with a variety of assessment methods and analysis to further identify and validate individual and group needs or diagnosis.
    4. Critical Evaluation and Risk Identification or Stratification:  Reflection on risk, condition, environment, and one’s own knowledge and skill and determination of next steps.
    5. Evidence-informed Approach: Seek and evaluate relevant research, literature, and expert opinion to ensure evidence-informed decision making across all elements.
    6. Goal Setting and Care Planning: Collaboratively establish goals, integrated plan of care, assignment of tasks or activities, and discussion of expected outcomes with the individual, family, community, and other care providers.
    7. Implementation: Implement evidence-informed integrated plan of care that is supportive of individual, family, and community goals.
    8. Transition Support: Collaborate to support transition planning to enable service access within or across streams of care, giving consideration of individual, family, and community needs, supports and environmental context.
    9. Evaluation: Ongoing critical clinical evaluation of relevant information and measures, including individual, family and community perspective, to adjust integrated plan of care as needed.
    10. Capacity Building: Information sharing to enhance the skills and abilities of the patient, family, their community, and care providers to support successful health outcomes.