The PRA+ Framework: A Structured Approach to Clinical Decision Making in Ultrasound Practice

Over the years, I have become increasingly aware that good ultrasound practice is about much more than obtaining a good image.

Ultrasound gives us the ability to see structures that we may previously have had to assume were there. But seeing more does not automatically mean making better clinical decisions.

We still need to understand what we are seeing, interpret what those findings mean for the individual patient, decide what action is appropriate and communicate that decision effectively.

This is the thinking behind the PRA+ Framework, which I developed as part of The Hackett Method.

PRA+ provides me with a structured way of thinking about clinical decision making throughout the patient journey.

It stands for:

P | Precision
R | Reasoning
A | Action
+ | Communication

P | Precision

The first question I ask is:

Is my assessment technically adequate to make an informed clinical decision?

For me, Precision means understanding the individual patient and the findings in front of me rather than relying solely on assumptions, standard protocols or textbook anatomy.

Depending on the clinical context, this may involve accurate anatomical assessment, appropriate ultrasound technique, identification of relevant structures, assessment of tissue characteristics and consideration of previous procedures or clinical history.

My guiding principle is:

Confirm, don't assume.

Ultrasound can provide information that changes my understanding of the anatomy or clinical presentation.

Precision means making sure I have obtained and recognised that information before moving on to the next step.

R | Reasoning

Once I have my findings, the next question I ask is:

What do these findings actually mean for this patient?

This is where I believe clinical reasoning becomes critical.

I need to integrate my ultrasound findings with the patient's:

• History
• Clinical presentation
• Anatomy
• Goals or concerns
• Previous treatment or relevant medical history
• Risk factors
• Expectations

I also need to recognise when habit or a familiar protocol may be influencing my decision more than the evidence in front of me.

Some of the reasoning errors I see can include anchoring to an established protocol, confirmation bias, allowing preference to override clinical considerations or overlooking factors that may affect whether a patient is ready or suitable to proceed.

For me:

Reasoning turns an observation into an individualised clinical decision.

A | Action

The next question I ask is:

Does my planned action logically follow from what I have found and reasoned?

Action isn't simply about knowing how to perform a procedure or obtain an ultrasound image.

It is about deciding what should happen next.

Depending on the clinical situation, appropriate action may mean:

• Proceeding with treatment or management
• Modifying my approach
• Performing further assessment
• Staging an intervention
• Pausing
• Referring
• Choosing not to proceed

One of the most important things I teach is that:

Knowing when not to act is part of clinical skill.

The appropriate action should be proportionate to the evidence and the individual clinical situation, rather than driven by habit alone.

+ | Communication

The final component of PRA+ is Communication.

The question I ask is:

Has the patient understood what I have found, what it means, what I recommend and what they can expect?

For me, communication is an important part of clinical care.

I need to be able to explain findings, recommendations, limitations, risks and expectations in language the patient can understand.

And when something unexpected or concerning occurs, communication becomes even more important.

I need to remain clear and calm, explain what is happening, provide concrete next steps and avoid minimising the situation or providing vague reassurance.

Communication is part of the clinical process, not an afterthought.

PRA+ in Practice

The way I apply PRA+ will naturally look different depending on the area of ultrasound I am performing.

In facial ultrasound, for example, I may identify an anatomical variation or previous product that changes my treatment plan.

In MSK ultrasound, I may identify findings that need to be considered alongside the patient's symptoms, clinical history and functional presentation before deciding what they mean and what should happen next.

The anatomy, pathology and clinical questions may be completely different.

But the thinking process remains the same:

Precision → Reasoning → Action → Communication

PRA+ Is Not Just a Checklist

I don't see PRA+ as something that should be considered at only one point during an examination or procedure.

It is a continuous thread throughout the clinical journey.

From the initial assessment, through imaging and interpretation, to decision making and communication, I want practitioners to continually consider whether their next decision is supported by the information available.

New information can change the clinical picture.

A scan may change my understanding of the anatomy.

A patient's history may change my assessment of risk.

A clinical finding may mean that further investigation or referral is appropriate.

Good clinical decision making means being prepared to respond to that information.

Where Does Ultrasound Fit?

I see ultrasound as a powerful tool for obtaining information about the structures being assessed.

But ultrasound does not replace clinical reasoning, judgement or accountability.

Seeing more is only valuable if I know how to interpret what I see and decide what to do with that information.

That is the purpose of PRA+.

It gives me a structure for asking:

What am I seeing?

What does it mean?

What should I do about it?

And how do I communicate that decision?

The PRA+ Questions I Want Practitioners to Ask

Before making a clinical decision, I encourage practitioners to ask themselves:

Precision

Do I understand the specific findings in front of me, rather than relying on assumption?

Reasoning

Have I considered the full clinical context, not just the imaging finding?

Action

Does my plan logically follow from what I have found and reasoned?

Communication

Has the patient understood the findings, plan, risks and next steps?

These questions are simple, but they help make the thinking behind clinical decisions more deliberate and consistent.

The Bigger Picture

I developed PRA+ because I believe technical ability is only one part of clinical competence.

Knowing how to acquire an image and understanding anatomy are essential, but they are only part of the process.

Strong clinical practice also requires accurate assessment, sound reasoning, proportionate action and effective communication.

Whether I am teaching facial ultrasound, MSK ultrasound or another area of ultrasound practice, these principles remain relevant.

Better imaging is valuable. Better clinical decision making is the goal.

The PRA+ Framework forms part of The Hackett Method, my educational approach to ultrasound education and clinical reasoning.