Physiotherapists need to be able to make their own judgements and decisions on the management of patients (2). They must act as autonomous practitioners, capable of making their own decisions - separate from the views of other practitioners (2). This domain reflects on the importance of having the necessary clinical reasoning skills and the importance of drawing on appropriate knowledge and skills to inform practice. In order to achieve this collecting information from a variety of sources, critically analysing the information and drawing reasoned conclusions supported by policy and evidence based thinking are valued at equal importance.

The first element of practice decision making is collecting information from a variety of sources relevant to the situation, using routine and some specialised approaches. During my placements. I recorded various occassions where I used these skills in a 'skills journal', which was then signed off by my educator. This included things like gathering history from previous notes, conducting subjective assessments to gather background information on patients, gathering blood pressure and oxygen saturation information from machines, auscultation and liaising with MDT during handovers to gather patient information. Gathering patient information accurately is an important part of the process as it allows you to form a picture of what is occurring and it informs the analysis of this information to create a treatment plan. I feel that gathering information is a strong area of my practice. When first beginning this process on placement 1, I was somewhat slow. Having completed 5 placements, I now feel I gather information in a timely manner. I put this change in practice down to having greater knowledge about what information I need and the best way to gather it. This has came about from increasing my patient mileage.

Critically analysing  information is just as important. This has been achieved at times by analysing investigations such as blood gases or chest x-ray in order to get a clear picture what the patient is experiencing. This is also seen in the 'A' of my 'SOAP notes'. Occasionally such methods have been done on wards in the absence of a medical examination or diagnosis from a doctor - this has allowed me to process relevant findings when information is incomplete. Analysing information such as this takes some practice particularly with x-rays, but I believe the more x-rays I observe on a regular basis the better I have been able to identify findings a physiotherapist should be looking out for such as a pneumothorax, consolidation or an enlarged heart. These skills have improved through practice ('ABG practice'), but also through having a systematic approach (A,B,C,D,E x-rays). My ability to process, analyse and interpret findings autonomously is important for a physiotherapist - as from experience, notes that have arrived from different departments such as a&e, often have important information incorrect, or missing. Therefore, the ability to collate all the information that I have had access to and analyse it, allows me to be able to practice safely and effectively within my own scope of practice. When graduated, I hope to get more experience interpreting orthopedic x-rays and MRI's. This will help to inform my practice, as sometimes it can take quite a significant period of time for these to be reported on. 

Using the information that has been analysed, the patients preferences, current policy and evidenced based thinking is part of the final decision making process and the clinical reasoning ability of the clinician (3). Each physiotherapist is required to be able to practise as an autonomous professional, exercising their own professional judgement. Drawing reasoned conclusions is a vital component of this. I have included 3 'clinical reasoning forms' to demonstrate my attempts to meet this criteria. These forms are based on 3 varying case studies on patients I have managed. They demonstrate how I gathered information from various sources, analysed it and arrived at a reasonable conclusion. This not only demonstrates the ability to draw on appropriate knowledge and skills to inform practice but also taking responsibility for your own actions. As evidence, I have also included 'placement feedbacks' on my clinical reasoning ability to show a combination of all the previously mentioned skills. As part of a remote placement, I was required to complete a 'case presentation' based on a case study of a patient I had assessed. This shows my reasoned decision making but also reflecting on the decision making process. I found the process of clinical reasoning difficult firstly, in particular in non-musculoskeletal areas. However the more theory and policy I gained knowledge of, the more patient mileage I gained and the more my rapport skills got better the easier this has become. In basic cases my clinical reasoning skills are good, however in some complex cases I will still look for advice and guidance from seniors.

In my opinion, an individuals level of practice decision making is somewhat based on their own patient mileage. Integrated clinical experience is reported to promote clinical reasoning (4). From this it would seem that the more experience and knowledge a person gets over time in a specified area (5) , the more developed their clinical reasoning will become. In this regard, I feel I am at the early stages of my journey. My ability to clinical reason has grown over the course of completing VIVA practical exams and gradually getting more clinical exposure throughout my placements. I aim for this process to continue when I graduate by gaining a broad knowledge of many areas of physiotherapy by completing rotations as a band 5. This will allow me gain experience in many different settings, which I can then draw on when making reasoned decisions. I will also seek feedback and advice on my clinical decision making from my seniors and colleagues.

As with many other domains, the COVID-19 outbreak which caused widespread national lockdowns in early 2020 has had its effects on decision making. As mentioned in order domains the prominence of telephone assessments and triages has grown since the start of the pandemic. This means that some information is now gathered over the phone. The negative of this lies in that a patient's body language can not be read over the phone, nor can an observation of the patient take place. What we are then left with is the patient describing their condition and concerns. Therefore the importance of subjective questioning has increased in order for vital information not to be missed. This has led to an increase in my own personal scope of practice. As my first placement was completely virtual, my clinical reasoning skills had to rely on only the subjective assessment to make informed decisions. This now means in practice, I am already reasoning during subjective history taking and not only after the full assessment is completed.