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Table 3-1

Steps to Make a Clinical Judgment from Assessment Data

StepDescription
1Identify abnormal cues and supportive cues (client strengths).
2Cluster cues.
3Draw inferences to propose or hypothesize clinical judgments (opportunity to improve health, risk for and actual client concerns/problems, collaborative problems, and/or referral to primary care provider).
4Identify possible client concerns.
5Validate the client concern with the client, family, significant others, and/or health team members.
6Document clinical judgments.