How to Apply the Conscious Decision-Making Framework


In the July case of the month, Austin — an occupational therapist (OT) working as an independent contractor in the auto insurance sector — performed an occupational therapy assessment for the client, Veronika. Veronika had been in a car accident six months prior and Austin recommended that she required 20 hours of attendant care and submitted his report to Prompt Rehab and GOHOME Insurance company. The insurance adjuster at GOHOME Insurance questioned the recommended 20 hours of attendant care stating that it may be difficult to find a service provider in the remote community where Veronika resided. They requested that Austin modify his report; Austin wondered what he should do. 


Here is the summary of how Austin used the Conscious Decision-Making Framework to arrive at his final decision.

Step One: Describe the Situation

  1. What are the facts of the situation?
    • Austin completed an OT assessment and documented his recommendations in a report, which was submitted to the rehabilitation company and the insurer. Austin’s recommendations of 20 hours of attendant care were challenged by the insurer as they were difficult to implement.
    • Austin has to review his report and recommendations to determine if they are justified and reasonable.
  2. What is the scope of the referral?
    • The scope of the referral is to complete an attendant care needs assessment and provide recommendations to the insurer about the number of hours of attendant care that are reasonable for the client.
    • Austin is only assessing the client, Veronika and is not providing any occupational therapy treatment to her.
  3. Who is the client?
    • The client is Veronika, who was in a car accident six months ago
  4. Who are the other stakeholders?
    • Prompt Rehab
    • GOHOME Insurance
  5. What is the underlying issues?
    • Austin must balance the competing priorities of his relationship with the insurance company (who pays for the occupational therapy assessment) and his duty to make recommendations that are justified and reasonable given Veronika’s situation. 
    • Austin must review his occupational therapy assessment and report to determine if he has sound rationale for his recommendations.  

Step Two: Identify the principles related to the situation

The principles as outlined in the Code of Ethics that apply to Austin’s situation:

  • Collaboration and communication: Austin has to interact and communicate with Prompt Rehab, GOHOME Insurance and Veronika in a professional and ethical manner;
  • Honesty and fairness: Austin has to complete an OT assessment that is fair, objective, and impartial;
  • Accountability: Austin is an autonomous practitioner who is accountable for his actions and decision-making. His recommendations should be justified and reasonable given his assessment of Veronika. Austin is expected to act in accordance with legislation, regulations and the standards and guidelines;
  • Transparency: Austin has to be transparent in his interactions with all stakeholders and be able to explain the rationale for his recommendations.

Step Three: Identify the relevant resources to assist with the decision-making

  1. Are there any relevant resources, such as legislation, regulations, standards or guidelines?
    • Austin examined the Standards for Occupational Therapy Assessments and determined that performance indicator 3.B.4 applied to his situation. 3.B.4 states that an occupational therapist will “determine the resources needed and their availability in relation to the recommendations.” In this situation, Austin looked at the homecare services that were available in the area where Veronika lived and determined that there were 2 companies that could provide services to her. Based on her needs and the fact that there were 2 companies in the area who could provide services to Veronika, Austin felt that his recommendations were reasonable.

    • Austin looked at the Standards for Record Keeping to determine what would happen if he decided to change his recommendations. He knew that he would have to distribute these new recommendations to all stakeholders. Performance indicator 3.10.2 informed him that “modifications to a document after the document has been distributed will only be accomplished through the use of addendum. Copies of the addendum will be sent to all recipients of the original document.”

    • Austin remembered that the College had released a document entitled Guidelines for Working with Third Party Payers. He read through the document and found a paragraph stating that: “When making a determination about the client’s requirements for care, the OT should follow the core values and principles of the Code of Ethics and make recommendations and decisions that are transparent, fair, objective and impartial. OTs must ensure recommendations and decisions are not biased in favour of the referral source, the payer or the client.” He reflected in this situation if he felt that he was being swayed by the insurer, the company he was contracting to (Prompt Rehab), or by Veronika. Although he did feel outside pressure from the third parties involved, he reviewed his recommendations and determined that they were fair based on his assessment results and could be implemented given that there were two home care companies in the area where Veronika lived. 

    • Austin remembered that the Ontario Society of Occupational Therapists (OSOT) had an Auto Sector working group. As he was already a member of OSOT, he logged onto their site and reviewed relevant resources, including a resource that outlined occupational therapists’ responsibilities when completing the Form 1.   
  2. Are there any individuals with expertise in the area?
    • Austin contacted his colleague, who was experienced in performing occupational therapy assessments in the auto sector, and who was also a member of the Ontario Society of Occupational Therapists (OSOT) Auto Sector working group.
  3. Is there any relevant evidence?
    • Austin did not feel that he needed any further evidence. 

Step Four: Consider if you need further information or clarification

  1. Do you understand the intent of the relevant legislation, regulations, standards or guidelines?
    • Austin felt that he understood the information contained in the resources noted above.
  2. What evidence exists?
    • In this case, there was no further evidence to review.
  3. Are there any missing facts? Have you identified the client’s best interests?
    • The client, Veronika, is entitled to a fair and impartial occupational therapy assessment that is supported by clinical rationale.
  4. Are all of the stakeholders and their interests identified?
    • Prompt Rehab: concerned about maintaining a working relationship with GOHOME insurance
    • GOHOME Insurance: concerned about the number of hours of attendant care that Austin recommended as it is difficult to find a service provider in the remote northern community where Veronika lives

Step Five: Identify the options 

  • In Austin’s situation, his options were to modify his report to reduce or eliminate the hours recommended or keep his report the same.

Step Six: Choose the best option 

    • Austin reviewed his report and believed he performed an objective occupational therapy assessment and his recommendations were based on witnessed observations of the client, Veronika.
    • He determined the recommended 20 hours of attendant care would ensure Veronika’s safety in her home and recommending fewer hours would pose a safety risk for Veronika.
    • Austin believed his recommendations were reasonable, unbiased, and transparent.

      Step Seven: Take action

      • Austin engaged in a dialogue with Prompt Rehab and GOHOME Insurance to clarify the recommendations outlined in his report and address any further questions. He explained the rationale for his decision and that his recommendation was realistic given there were two home care companies that serviced Veronika’s area, and based on the standards and guidelines of his College, he had completed a fair, objective and unbiased assessment.
      • Austin made a notation in the clinical record about the situation and documented the discussions he had with Prompt Rehab and GOHOME Insurance. 
      Note: If Austin had reviewed his original report and decided to change his recommendations, he would have to send an addendum to all recipients of the original document as outlined in the Standards for Record Keeping. He would document his decision-making, rationale and pertinent discussions with stakeholders in the clinical record and ensure a copy of the updated report was also placed in the clinical record.

      Step Eight: Evaluate the decision 

      • Austin was confident in his final decision and believed his report was reflective of his professional judgement and clinical rationale. 


      After Austin worked through the Conscious Decision-Making Framework, he documented his final decision and rationale for his decision in Veronika’s clinical record. He stated that he reviewed his occupational therapy assessment, report and recommendations and believed they were reasonable and sound to ensure Veronika’s safety considering her situation.   



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