Table 6.

The phases of clinical reasoning process ¹ with descriptions for the pharmacy context and examples from the think aloud data.

Process	Description	Example of Pharmacists’ Thinking
1. Consider prescription in context	Review legal and therapeutic aspects of prescribed medicine order Describe patient and context	I can see that an adult female patient is collecting a prescription for a penicillin antibiotic and insulin. I’m just checking the script to see if it is legal and valid—if it’s in date and the medication order is signed by the prescriber.
2. Retrieving information	Gather medication history from patient	Do you have any allergies, particularly to penicillin?
	Review dispensing history, laboratory/diagnostic information	“I would establish if these are new medicines for this patient or if they have changed by looking up their dispensing history.” “I am asking about BSL levels to ascertain the level of diabetes control and look at medication administration in the context of overall disease management.”
	Recall information from past/previous experience	“I have seen diabetic patients with infections have fluctuating and higher than usual blood glucose levels.”
	Investigate new information e.g., directed searching in drug information databases	I am just going to check the therapeutic guidelines to see if this is the right duration of antibiotic treatment for a diabetic leg ulcer.
3. Processing information	Recognise the difference between normal and abnormal by comparing information	What I’m looking for is if there is anything unusual or different about this prescription that stands out compared to what I am used to seeing.
	Distinguish between information which is relevant from irrelevant;	The antibiotic prescribed is penicillin, so I need to be looking for allergies but Matilda has no history of penicillin allergy. For this script we don’t need be concerned about her morphine allergy.
	Relate information to identify patterns of information	I see that oral hypoglycaemic agents have not achieved optimal [diabetes] control and lifestyle interventions have not helped BSL levels and now there are some complications of high blood sugar starting to appear, including leg ulcer. So Matilda’s diabetes control is deteriorating.
	Match similar information and/or: identifying a mismatch between two pieces of information	Matilda has been using the Byetta and that requires injections, so this information tells me how acceptable administering a new drug [insulin] in the same form would be. So that immediately makes me pull up as to why a doctor would be prescribing an antifungal for an ulcer. I can’t think of any kind of therapeutic reason why that would be the case so that would require further investigation.
	Prioritise information by ranking its importance	Matilda has a number of chronic health conditions, so it is about prioritising what information you are able to give her in the short time you have available.
4. Identifying medication-related issues	Synthesise information to formulate immediate issues that need to be addressed	There is a duplication of hypoglycaemic agents that makes hypoglycaemia more likely in this patient.
	Secondary issues that need to be addressed	I can see the patient is complacent about their lifestyle aspects of diabetes management.
5. Collaborative planning	Elicit ideas and opinions	Tell me how you feel about starting insulin and going home tonight to administer for the first time.
	Anticipate what to expect	The antibiotic is broad spectrum and may cause diarrhoea or thrush. I could recommend a probiotic to minimise the chance of this occurring and am asking how Matilda would feel about this, because it will be an extra expense and extra medication to take.
6. Decision making	Verify correct information	I look at the drug information on the script and check that against the dispensed item. I am checking the name of the medication [amoxycillin + clavulanic acid] and its strength [875/125] against both the label on the product and the box itself. Then the directions [1 tablet every 12 h]. Then I check the quantity [10] so this is all correct.
	Justify thoughts and actions	Insulin and metformin is an acceptable combination for Type 2 diabetes and the prescription is entirely legitimate.
	Select appropriate interventions to optimise patient outcomes	I recommend Matilda go back to her GP and the GP will measure the outcomes of the new medications. A diabetes educator can assist with overall disease state management. She could also come back to the pharmacy, to get her blood glucose measured, have a HMR or diabetes MedsCheck, have their BP monitored.
7. Reflection	Contemplate what was done well and what could have been done differently	I should have asked more about their reflux—it could have been related to diabetic gastroparesis. I would not usually have this long to spend with a patient in the pharmacy.

¹ Adapted from [17,29,30,31].