Standards of Practice for Alberta Physiotherapists

Updated May 2011

Standards refer to the expected level of physiotherapist performance, for qualification to practice, clinical care, and professional practice that results in safe, ethical and effective physiotherapy service. Application of these standards will vary depending upon the context of an individuals physiotherapy practice. In response to emerging professional regulatory, legal and ethical expectations, the standards will evolve and undergo revision.

Physiotherapy Alberta regulates and leads the practice of physiotherapy in Alberta. 300, 10357 - 109 Street, Edmonton, Alberta T5J 1N3 T 780.438.0338 | TF 1.800.291.2782 | F 780.436.1908 info@physiotherapyalberta.ca
* The College of Physical Therapists of Alberta operates as Physiotherapy Alberta College + Association.

Contents
Introduction ........................................................................................................................... 4 Professional Qualifications and Competence:
y

Entry to practice + essential competence .................................................................... 6

Physiotherapist-Client Relationship:
y y

Client-centered service ................................................................................................ 7 Professional boundaries ................................................................................................ 8

Professionalism:
y y y

Legislative compliance................................................................................................... 9 Conflict of interest ......................................................................................................... 10 Title and credentials ...................................................................................................... 11

Practice Management:
y y y y y y y y y y

Dual registration ............................................................................................................ 12 Concurrent treatment ................................................................................................... 13 Safety.............................................................................................................................. 14 Supervision ..................................................................................................................... 16 Advertising and promotional activities ......................................................................... 17 Fees and billing .............................................................................................................. 18 Human resources ........................................................................................................... 19 Record keeping and management ................................................................................. 20 Clinical, financial and equipment maintenance records .............................................. 22 Quality improvement ..................................................................................................... 25

Appendix I - Glossary ........................................................................................................... 26 Appendix II - Assignment of services to support personnel under supervision and direction of a physiotherapist................................................................................................. 29 Appendix III - Standards of practice development ............................................................... 30

Introduction
In Alberta, physiotherapists are legislated by the Health Professions Act (HPA) and registered with the College of Physical Therapists of Alberta1 (the College) to provide human health services.2 In accordance with the legislation, the College is required to adopt or develop standards for the practice of the profession in Alberta. Physiotherapists are regulated, primary health professionals who practice independently and/or as part of inter-professional teams to provide effective, ethical and safe client-centered service. Within the practice of physiotherapy, physiotherapists: delivery of quality physiotherapy services is a focus on how services are structured and managed. Standards refer to the expected level of physiotherapist performance, for qualification to practice, clinical care, and professional practice5 that results in safe, ethical and effective physiotherapy service. The application of standards will vary depending upon the context of an individuals physiotherapy practice. In response to emerging professional regulatory, legal and ethical expectations, the standards will evolve and undergo revision. The Standards of Practice for Alberta Physiotherapists (standards) are now described in a compendium of foundational profession-specific documents including:

yy Assess, treat, prevent and manage injury,

pain, disease and/or disorders.

yy Essential Competencies for Physiotherapists in

Canada, 2009.

yy Optimize clients3 physical function,

functional independence, mobility and quality of life.

yy Code of Ethics. yy Standards for Practice described herein.

These standards were developed6 to:

yy Educate clients and others4 about health,

wellness, fitness and self-management. Physiotherapy services are provided to individual clients as well as groups or populations. Physiotherapists apply a client-centered, evidenceinformed approach to assessment, determining a physiotherapy diagnosis, treatment planning and intervention, and outcome evaluation. Inherent in the

yy Define performance expectations for the

delivery of quality physiotherapy service.

yy Provide reference for the public, the

profession and others regarding performance expectations for Alberta physiotherapists.

yy Provide guidance for physiotherapists

and others in evaluating and maintaining competence.

1. 2. 3. 4. 5.

Legal name is the College of Physical Therapists of Alberta; however, we operate as Physiotherapy Alberta College + Association. Physiotherapists are registered to provide services in the human health services sector. The provision of animal health services is outside the scope of practice of physiotherapists in Alberta and is regulated according to the Veterinary Profession Act. Client is a generic term used to refer to patients or groups of individuals/populations who can benefit from physiotherapy services. Others may include family, caregivers, teachers, social workers etc., as defined according to the context of practice. Professional practice refers to providing quality, ethical and accountable physiotherapy services within a dynamic and complex public and private health system. While many factors impact professional practice including the practice environment, organizational structure, policies and procedures, and available resources, physiotherapists are expected to meet these standards as applied within the context of their practice. A description of the development of the standards is found in Appendix III (see page 30).

6.

Physiotherapy Alberta Standards of Practice - updated May 2011

yy Provide a reference for reviewing and resolving

professional practice and conduct issues.

yy Identify the outcomes that clients may expect

when physiotherapists provide services. In addition to being satisfied that the specific outcomes identified for each standard are met, clients will also be satisfied that:

yy Physiotherapy services delivered were

safe and comprehensive.

yy They had an opportunity to provide input

into the physiotherapy services received and were able to make choices based on information provided and felt their decisions were respected.

yy Physiotherapy services were provided in

an honest, timely, professional and ethical manner.

In the event of any inconsistency between the standards and governing legislation, legislation will prevail. Please contact the College if further information is required.

Physiotherapy Alberta Standards of Practice - updated May 2011

Professional Qualifications and Competence

Entry to Practice and Essential Competence
To practice as a physiotherapist in Alberta, individuals must be registered with the College. The competencies required for entry to the profession and required throughout ones career are described in the Essential Competency Profile for Physiotherapists in Canada (ECP), 2009. During the lifespan of ones career, physiotherapists must work:

Expected outcomes
Clients are satisfied that:

yy Physiotherapists meet standards for entry to

the profession and continued practice.

yy Knowledge, skills and abilities of physiotherapists

contribute to the delivery of quality service.

Resources

yy Within the scope of physiotherapy practice. yy At a level of competence that meets or

exceeds the Colleges standards.

yy National Physiotherapy Advisory Group. Essential

Competency Profile for Physiotherapists in Canada, 2009.

Physiotherapists demonstrate this standard by:

1. Successfully meeting entry level practice requirements based on the Essential Competency Profile. 2. Being familiar with and meeting competencies set out in the Essential Competency Profile throughout their career. 3. Always working within their level of competence.

Physiotherapy Alberta Standards of Practice - updated May 2011

Physiotherapist - Client Relationship

Client-centered Service7
Physiotherapists must demonstrate a client-centered approach recognizing the importance of client involvement and participation in key decisions about physiotherapy services, ones own health and the environment or situation in which a client lives, works and plays. 9. Working in collaboration with other health care team members and organizations to ensure client needs/goals are met. 10. Providing information to help clients self-manage their health.

Physiotherapists demonstrate this standard by:

1. Demonstrating respect, sensitivity and understanding toward all clients. 2. Valuing the clients best interest. 3. Communicating effectively8 at the outset and throughout the course of service delivery to ensure clients fully understand physiotherapy services offered and how those services will meet their needs. 4. Referring to other health care providers as appropriate when further assessment is required. 5. Supporting client participation and choice about physiotherapy services offered, including decision to refuse service or revoke consent. 6. Obtaining client or their legally authorized representatives informed consent9 to proceed with an agreed course of physiotherapy treatment/services both initially and on an ongoing basis. 7. Appropriately establishing and managing therapeutic relationships with clients. 8. Appropriately terminating the therapeutic relationship giving consideration to the criteria for transfer of care or discontinuation of services as outlined in the Colleges guides: Establishing and Maintaining Therapeutic Relationships or Managing Challenging Situations.

Expected outcomes
Clients are satisfied that:

yy Communication regarding physiotherapy service

was clear, accurate and understandable.

yy Their preferences and needs were considered

when provided with health information and options for care.

yy Sufficient information was provided to ensure

that their consent was informed.

yy Their input into planning and participating

in the service was important, valued and respected.

yy They were provided with strategies/resources

to self-manage their health condition.

yy A therapeutic relationship was established and

maintained with the physiotherapist.

Resources

yy Physiotherapy Alberta. Therapeutic Relationships:

Establishing and Maintaining Professional Boundaries: A Resource Guide for Physiotherapists, 2007.

yy Physiotherapy Alberta. Managing Challenging

Situations: A Resource Guide for Physiotherapists, 2007.

yy Physiotherapy Alberta. Practice Guideline:

Informed Consent, 2008.

7. 8. 9.

Client-centered service is an approach in which physiotherapists value and respect partnerships with those receiving physiotherapy services. Effective communication includes elements such as verbal and non-verbal communication, body language, tone. Consent is an ongoing process of communication and therefore it should not be documented as an onetime event.

Physiotherapy Alberta Standards of Practice - updated May 2011

Physiotherapist - Client Relationship

Professional Boundaries
Professional boundaries are the foundation of trusting inter-professional and client therapeutic relationships. The professional role places physiotherapists in positions of authority or power in which they are expected to establish and maintain professional boundaries with co-workers, clients, students or subordinates by acting responsibly, appropriately and with integrity at all times. Physiotherapists must maintain appropriate professional boundaries. Physiotherapists must not misuse or abuse their position of authority or power by crossing professional boundaries and must seek to reestablish a boundary or respond to situations where boundaries have the potential to be compromised. 4. Identifying, discussing and attempting to resolve issues or seeking advice when the potential for compromising boundaries exists on the part of the physiotherapist or the client. Terminating the therapeutic relationship if professional boundaries cannot be established or maintained giving consideration to transfer of care strategies and dis-continuation of services criteria described in Physiotherapy Albertas guides on Therapeutic Relationships and Managing Challenging Situations. Maintaining appropriate professional boundaries and never making abusive, suggestive or harassing comments, inappropriate non-consensual physical contact or sexual advances with co-workers, students or subordinates.

5.

6.

Physiotherapists demonstrate this standard by:

1. Understanding the differences between nonprofessional and professional relationships and boundary warning signs as described in the Colleges Therapeutic Relationships: Establishing and Maintaining Professional Boundaries, 2007. 2. Developing therapeutic relationships with clients ensuring appropriate boundaries that consider the elements of power, trust, respect, and physical closeness as described in the Colleges Therapeutic Relationships: Establishing and Maintaining Professional Boundaries, 2007. 3. Acting respectfully and responsibly at all times, and never making: a. Physical contact that is inappropriate for clients condition, of a sexual nature or is a violation of professional boundaries. b. Sexually suggestive comments or sexual advances, or engaging in sexual relations with clients.

Expected outcomes
Clients are satisfied that:

yy A therapeutic relationship with appropriate

professional boundaries was established and maintained. Co-workers, students or subordinates are satisfied that:

yy An appropriate professional boundary was

established and maintained.

Resources

yy Physiotherapy Alberta. Therapeutic Relationships:

Establishing and Maintaining Professional Boundaries; A Resource Guide for Physiotherapists, 2007.

yy Physiotherapy Alberta. Managing Challenging

Situations; A Resource Guide for Physiotherapists, 2007.

Physiotherapy Alberta Standards of Practice - updated May 2011

Professionalism
Legislative Compliance
Physiotherapists must comply with all legislation and regulations that applies to the practice of physiotherapy.
2.

Being familiar with changes in legislation governing their physiotherapy practice.

Expected outcomes Physiotherapists demonstrate this standard by:

1. Being familiar with and practicing according to all legislation that applies to their physiotherapy practice which includes, but is not limited to: Clients are satisfied that:

yy Services were provided in accordance with

applicable legislation, regulations and professional obligations.

yy Personal information was protected.

Resources

Health Professions Act and regulations. Standards of Practice and Code of Ethics. Privacy legislation - Health Information
Act, Personal Information Protection Act, and Personal Information and Protection of Electronic Documentation Act.

yy Health Professions Act and Physical Therapists

Profession Regulation available from the Alberta Governments Queens Printer at www.qp.gov. ab.ca/catalogue.

Practice related legislation Workers

Compensation Act, Insurance Act, Diagnostic Treatment Protocol Regulation, Laser Radiation Protection Act and Public Health Act.

yy Physiotherapy Alberta. Privacy Guide for Alberta

Physiotherapists, 2008.

Physiotherapy Alberta Standards of Practice - updated May 2011

Professionalism
Conflict of Interest
Conflicts arise when/if physiotherapists have a relationship or interest that could be seen as improperly influencing their professional judgment or ability to act in the clients best interest. Physiotherapists must avoid all situations and circumstances that may result in a real, potential or perceived conflict of interest. 4. Refraining from providing physiotherapy services to a related person unless: Another physiotherapy provider is not available. No fee is charged. Relationship is disclosed to payors and any others receiving information or reports pertaining to the related person when the information provided is relied upon for health, administrative or legal decisions or actions involving the related person.

Physiotherapists demonstrate this standard by:

1. Not participating in any activity in which professional judgment could be compromised or is for the sole purpose of personal gain. 2. Disclosing to clients and documenting in clients record the purchase of products/ services in which the physiotherapist or related person has a financial interest in the vendor. 3. Not entering into agreements in which they or a related person receives a benefit1 related to: the volume of service provided, number or type of referrals made or received, services delivered, or the sale of products offered within the practice.

5. Ensuring the formal processing and documentation of all physiotherapy services provided to friends or colleagues. 6. Disclosing information to the Registrar about any activity or arrangement that may constitute a conflict of interest for themselves or a related person.

Expected outcomes
Clients are satisfied that:

yy The physiotherapist behaved in an honest,

professional and ethical manner.

yy The physiotherapists actions were in the

interest of achieving physiotherapy goals.

10.

Benefit refers to any gift, advantage or payment of any kind other than those that are derived from payment for services delivered in accordance with the fee schedule. This is not intended to prohibit gifts (giving or receiving) of token value as a form of appreciation.

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Professionalism
Title and Credentials
Physiotherapists must use their protected title while engaging in physiotherapy practice and when identifying themselves to clients and others. Other credentials (e.g., education degrees or certifications) may be used to the extent they are generally understood by the public and the profession, and only used in conjunction with the protected title. 5. Using any education credential associated with the title Doctor or Dr. in accordance with the regulations and any criteria established by Council. 6. Using credentials associated with specialization of physiotherapy practice in accordance with the regulations and any criteria established by Council. 7. Ensuring their physiotherapy position or job title meets the expectations in this standard.

Physiotherapists demonstrate this standard by:

1. Using one of the following protected titles if on the General or Courtesy Register:

Physiotherapist Physical therapist PT

2. Using one of the following protected titles if on the Provisional Register:

Expected outcomes
Clients are satisfied that:

yy Information about title and credentials of the

physiotherapist delivering the service was clear, understandable and helpful when making choices about a service provider.

Physiotherapist intern Physical therapist intern

3. Ensuring the use of any credentials is in conjunction with their protected title and is represented accurately and in a way that has meaning for the public and/or profession. 4. Ensuring credentials always follow the protected title (e.g., Terry Smith, PT, BSc.PT, and B.A).

Resources

yy

Canadian Alliance of Physiotherapy Regulators. Official Marks, February, 2010.

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Practice Management
Dual Registration
Physiotherapists registered as another regulated health professional in Alberta must administer each health service as a separate and distinct entity and ensure that clients understand the role when providing each of the separate and distinct health care services. Examples include physiotherapists who are also registered as a/an: 2. Ensuring each health and business practice is separate and distinct by having: Different or separate billing and financial records. Separate client records or different entries in the client record. Separate appointment books and/or distinct days and times for providing each service.

yy Acupuncturist yy Chiropractor yy Naturopath yy Occupational therapist yy Osteopath

Physiotherapists demonstrate this standard by:
1. Ensuring clients receive adequate information to understand the differences in health provider roles and which service is provided.

3. Ensuring clients receive services they initially sought, unless those services are not in the clients best interest. 4. Ensuring the client record clearly demonstrates which service was provided at each visit.

Expected outcomes
Clients are satisfied that:

yy Nature of service and providers role was clear.

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Practice Management
Concurrent Treatment
Concurrent treatment is the provision of the same or similar health service(s) by more than one health practitioner, including another physiotherapist, for the same or related injury or disease during the same episode of care. Physiotherapists must enquire about care provided by other practitioners and only provide concurrent treatment when, in their professional judgment, the physiotherapy treatment is required, is in the best interest of the client, and their treatment approach is compatible with the other practitioner. Consultation and communication with other provider(s) and client has occurred. Treatment is coordinated on an ongoing basis.

6. Not providing concurrent treatment when:

There is conflicting treatment approach or

philosophy between health providers that cannot be resolved through communication and collaboration.

Additional physiotherapy services represent

duplication or inefficient use of human and/or financial resources and/or the risks outweigh benefits of concurrent treatment.

Physiotherapists demonstrate this standard by:

1. Establishing and communicating concurrent treatment objectives and ensuring they are understood by the client. 2. Identifying and managing risks and documenting communication of any risks11 involved with providing concurrent treatment. 3. Communicating and documenting a decision not to provide concurrent treatment to the client. 4. Ensuring client understands funding implications. 5. Providing concurrent treatment only when: Treatment is appropriate and in the clients best interest. Treatment is complementary to that provided by other health provider(s).

Expected outcomes
Clients are satisfied that:

yy The role and expectations of the physiotherapy

provider in meeting the clients needs were clear and understandable.

yy Treatment was complementary and resources

used are appropriate.

11. Risks can include risks to the client and the practitioner. Examples of risk include liability issues or actual harm due to conflicting treatment.

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Practice Management
Safety
Physiotherapists are committed to safety12 for clients, health providers and others, and strive to promote a culture of safety in all aspects of their professional practice. Physiotherapists must deliver physiotherapy services safely and effectively and ensure a safe practice environment.13 5. Responding to any adverse events or close calls. Once a situation is identified or recognized, responding effectively and in a timely manner to mitigate client harm, ensure disclosure and prevent reoccurrence. 6. Only using techniques or equipment they are educated, trained and competent to use. 7. Complying with infection prevention and control standards, guidelines, policies, and procedures appropriate to their area of practice and meeting performance expectations outlined in the Colleges infection prevention and control documents. 8. Understanding and complying with personal health and safety policies and practices. Examples include, but are not limited to: managing work related injury and illness, complying with immunization, taking precautions regarding safety under specific conditions, e.g., home visits or after-hours service, practicing hand hygiene and wearing appropriate personal protective equipment when required. 9. Ensuring the physical environment is safe and free of hazards to minimize risks to clients, service providers and others. 10. Ensuring therapeutic equipment used is in safe working order and is maintained in accordance with manufacturers instructions at least annually or more frequently if required. 11. Ensuring appropriate protective equipment is available and used correctly.

Physiotherapists demonstrate this standard by:

1. Maintaining and applying current health and safety knowledge of practice environment which may include, but is not limited to: best practices, protocols, policies and procedures, standards and/or relevant legislation. 2. Advocating for safety best practices, protocols, policies and procedures, standards, and compliance with safety related legislation to owners, operators and administrative staff responsible for the planning and delivery of physiotherapy services. 3. Complying with applicable facility or health system communication protocols or reporting requirements regarding adverse events, delivery of safe services and maintenance of a safe environment. 4. Ensuring client safety at all times including anticipating, recognizing, managing and communicating any risk situations to client or others as appropriate.

12. Patient safety is the reduction and mitigation of unsafe acts within the healthcare system through the use of best practices which contribute to quality outcomes. (Canadian Patient Safety Institute and the Royal College of Physicians and Surgeons of Canada. The Safety Competencies Framework. www.patientsafetyinstitute.ca/english/education/safetyCompetencies). 13. Practice environment varies widely, ranging from providing services in a large hospital setting, to a private clinic or clients home in the community.

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Expected outcomes
Clients are satisfied that:

yy Government of Alberta. Handbook of Occupational

Hazards and Controls for Physiotherapy, Occupational Therapy and Respiratory Therapy Personnel: www.employment.alberta.ca/documents/WHS/ OHS-WSA-handbook-therapists.pdf www.employment.alberta.ca/documents/WHS/ OHS-WSA-knowledge-therapists.pdf

yy Information about potential risks involved was

provided and clearly explained.

yy Appropriate infection prevention and control

practices were followed.

yy Physiotherapy services were delivered safely. yy Any adverse event was handled effectively
to reduce/minimize the impact to the client including the risk of injury or infection and to prevent recurrence.

yy Alberta Health and Wellness medical device

reprocessing standards and bulletins - www. health.alberta.ca/newsroom/pub-infectionprevention.html : Single-Use Device Reprocessing Standards, January 2008. Reusable Medical Device Reprocessing Standards, January 2008. Manufacturer/Distributor Reprocessing Information Bulletin, June 2008.

Resources

yy Physiotherapy Alberta. Position Statement:

Infection Control, 2008.

yy Canadian Patient Safety Institute. www.

patientsafetyinstitute.ca: Canadian Disclosure Guidelines. Safety Competencies: Enhancing Patient Safety Across the Health Professions.

yy Alberta Occupational Health and Safety. www.

employment.alberta.ca: Workplace Health and Safety. Radiation Protection Act. Occupational Health and Safety Code.

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Practice Management
Supervision
Physiotherapists are responsible and accountable for all physiotherapy services delivered to their clients, including services assigned to other personnel14 working under their direction and supervision. Physiotherapists must only assign tasks to other personnel that they and the person to whom a task is assigned are competent to perform. 9. Communicating regularly and effectively with personnel to whom services are assigned. 10. Arranging a transfer of supervision when the physiotherapist is no longer available to provide supervision or direction. 11. Communicating to employers and clients that physiotherapy delivered by personnel supervised/directed by a physiotherapist should cease when the physiotherapist is no longer employed and no other registered physiotherapist is available to supervise.

Physiotherapists demonstrate this standard by:

1. Ensuring clients understand the roles, responsibilities and accountabilities of all personnel involved in the delivery of their physiotherapy services. 2. Obtaining client consent for the involvement of other personnel, under the direction and supervision of the physiotherapist, providing physiotherapy services. 3. Evaluating the knowledge, skills and abilities of all personnel to ensure they have the competence to deliver the services assigned.15 4. Assessing and determining the required type and level of supervision. 5. Assigning service tasks to support personnel in accordance with Appendix II. 6. Supporting the development and maintenance of knowledge, skills and abilities of other personnel involved in the delivery of physiotherapy services. 7. Regularly evaluating the role and services provided by other personnel and making changes as needed. 8. Regularly re-assessing client progress and adjusting services provided by other personnel.

Expected outcomes
Clients are satisfied that:

yy They understand the role, responsibilities and

accountabilities of all personnel involved in their physiotherapy care.

yy The physiotherapy services assigned to other

personnel are appropriate and performed competently under the supervision of the physiotherapist.

Resources

yy Physiotherapy Alberta. Supervision Resource Guide,

2008.

yy Canadian Alliance of Physiotherapy Regulators

and Canadian Physiotherapy Association. Essential Competencies of Physiotherapy Support Personnel in Canada, 2002. www.physiotherapy.ca/ PublicUploads/229100Essential%20Competencies_ Support%20Worker_2002.pdf.

14. Personnel may be defined as support personnel, therapist assistants, students, or any other health providers who

are providing physiotherapy services or carrying out tasks which are being directed and supervised by registered physiotherapists. 15. Appendix II provides detailed information about assignment of tasks specific to support personnel.

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Practice Management
Advertising and Promotional Activities
To help clients make informed choices regarding physiotherapy services, physiotherapists may advertise services within the professions scope of practice, to one or more individuals, the public generally, or other health professionals using any public16 medium. Advertising must be generally acceptable to the public and the profession. Physiotherapists must not provide clients, directly or indirectly, with incentives or other inducements to obtain or continue with physiotherapy services.17 Guarantees success of service(s) unless claims are supported by evidence available to the public. Provides comparative or superlative statements about service quality, health providers or products. Deprecates another regulated member, other health provider, clinic or facility. May be interpreted as an endorsement or recommendation about any product, brand or piece of equipment available for sale by a physiotherapist or within their practice.

Physiotherapists demonstrate this standard by:

1. Ensuring that the advertisements content is: factual, accurate, verifiable, not deceptive, includes all relevant information and does not harm the integrity of the profession.

3. Refraining from using client incentives or other inducements20 including but not limited to: Discount coupons or gift certificates for a service or product. Time-limited pricing or fees for a service or product. Prizes or gifts of a service or product.

2. Ensuring that the advertisement does not contain information that: Promotes unnecessary services. Offers to the general public free18 or discounted services that vary from the clinics fee schedule.19

Expected outcomes
Clients are satisfied that:

yy Information advertised about services/products

was accurate and helpful in making an informed choice about physiotherapy services.

yy Promotional activities did not unduly influence

over physiotherapy management decisions.

16. Public media includes electronic, print or oral communications. 17. Services include products that a physiotherapist may have available for sale to clients. 18. Free consultation is only to be used for the purpose of informing the public about physiotherapy services offered and

rendering an opinion about the propriety of physiotherapy services to that patient. No paid services can occur on the same day as a free consultation. A record of free consultations must be maintained and where appropriate transferred to a patients clinical record. 19. Regulated members are required to have an explicit fee schedule. Where free consultations or discounted services are provided, they must be included in the fee schedule and posted for all patients. 20. This does not prohibit a physiotherapist from making charitable donations for non-physiotherapy services or products.

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Practice Management
Fees and Billing
Physiotherapists must ensure that clients are provided with all fee information prior to service being delivered. All fees charged must be recorded in the financial record, invoiced in a timely manner, transparent and verifiable. Depending on the practice environment there may be a shared responsibility between the physiotherapist and an employer, owner or manager. 5. Ensuring clients are provided with accurate and comprehensive information about billing policies and procedures and receive in a timely manner, complete and transparent invoices for services, including interest and any other charges. 6. Regularly reviewing invoice and billing practices to verify timeliness, accuracy and appropriate use of registration number. 7. Taking immediate action to remedy any fee or billing discrepancies. 8. Maintaining a financial record in accordance with the Record Keeping and Management and Clinical, Financial and Equipment Maintenance standards.

Physiotherapists demonstrate this standard by:

1. Ensuring current knowledge of physiotherapy and health services funding and compliance with funding requirements, policies and procedures. 2. Ensuring there are established fee schedules that includes all fees that may be charged including, but not limited to: Fees for all physiotherapy services. Report fees or fees21 for chart copies. Interest charges, Equipment purchases. Charges for cancellations or no shows.

Expected outcomes
Clients are satisfied that:

yy Service fees/costs were clearly and appropriately

communicated.

yy A complete financial record is available and

can readily be provided to the client or other authorized individuals.

3. Establishing and communicating fees and billing policies and procedures to clients and payors. 4. Ensuring that fees charged are justifiable.

yy They were only charged for services rendered.

21. In some cases privacy legislation (i.e., Health Information Act) establishes the fees that can be charged for reports and chart

copies.

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Practice Management
Human Resources
Physiotherapists who own or operate a physiotherapy corporation or who are responsible in any way for the management of physiotherapy services must ensure there are appropriate human resources to deliver the services offered. Staff may include physiotherapists or other staff required to deliver services. 5. Staff is provided with an orientation to the physiotherapy service and organizations operations, policies and procedures. 6. Each staff member has a documented position description and contract or letter of employment. 7. Processes exist for staff to communicate human resources issues. 8. Staff has probationary and regular performance evaluations. 9. Only authorized personnel perform restricted activities in accordance with regulations or other criteria established by Council.

Physiotherapist owners, operators or managers demonstrate this standard by ensuring that:

1. Staff has appropriate education, training and experience, to deliver safe and effective physiotherapy care/service. 2. Staffing is adjusted to deliver safe and effective physiotherapy service. 3. Physiotherapists are registered with the College. 4. Staff is identified using appropriate title and credentials.

Expected outcomes
Clients are satisfied that:

yy Staff were available and appropriate for the

physiotherapy services provided.

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Practice Management
Record Keeping and Management
Record keeping is an essential component of quality physiotherapy care. Quality record keeping and management enhances client outcomes, facilitates the smooth transfer of client care to other providers, supports discharge planning, documents the management of the physiotherapy practice, and demonstrates professional accountability. Careful management of records is important for providing clients with ongoing access to their health information, ensuring accountability for services delivered, legal or disciplinary proceedings, and safety and risk management. Records are legal documents and include health, financial, equipment management and practice related information. Clinical and financial records document the history of client care and products and services provided. Physiotherapists must create and maintain clinical, financial and other practice management records that document the management of their client care and physiotherapy practice. 5. Including the following information to any discrete part (e.g., each page) of the physiotherapy record: Health information custodian/gatekeeper responsible for coordinating physiotherapy service delivery (i.e., name of clinic or facility). Date entry made. Name and signature or unique identifier of person(s) making the entry. When record relates to client care, clear client identification (i.e., clients name and birth date, or a unique identifier).

6. Ensuring, in situations when the client care or other services (i.e., maintaining equipment used in patient care) is delivered by support personnel, that tracking methods exist such that personnel providing client care or other services can be determined. 7. Ensuring that, the complete or any component of the record, can be retrieved and copied or printed regardless of the media (paper or electronic) used to create the record. 8. Ensuring that protocols or descriptions of the service delivered or care provided are documented in policy and procedure and can be referenced and retrieved when facility-based exceptions to expected record keeping practices, such as charting by exception, is used. 9. Documenting changes or additions made in records in a manner that retains the content of the original entry and includes: a. Clear identification of the person making changes or additions. b. Date change was made (e.g., incorrect entries crossed out, such that original information is still visible and initialed, correct information entered, or electronic tracking of the date of change, original content, added content and unique identifier of person making new entry).

Physiotherapists demonstrate this standard by:

General: 1. Maintaining accurate, legible22 and complete records in accordance with the standards of practice. 2. Keeping abbreviations to a minimum and helping anyone accessing the records understand abbreviations, acronyms or diagrams used.23 3. Ensuring records comply with all relevant legislation intended to protect the privacy and confidentiality of personal and health information.24 4. Understanding and communicating professional obligations regarding record keeping and management to employers, health service providers to whom services are contracted, support personnel or others under supervision.

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10. Periodically auditing records to ensure they are maintained in accordance with College guidelines and standards. Retention and disposal: Physiotherapists establish record retention and disposal processes that ensure records are properly retained and disposed of. At a minimum these processes will ensure: 1. Compliance with minimum retention periods defined by the College.25 Currently these are: a. For clinical and financial records minimum of ten (10) years after the last date of service provided to client. With minors, client records are retained for ten (10) years past minors 18th birthday. b. For equipment records - minimum of five (5) years. 2. The security of records in a location and manner that protects all parties and any personal and health information including situations when records are being transported. 3. Records are destroyed according to generally acceptable methods (e.g., shredding or de-identifying personal and health information) in a manner such that security and confidentially of information is maintained.

Ongoing records management: Physiotherapists who maintain custody and control of records (or those who are the most responsible for records) in a physiotherapy practice must ensure there are plans in place for all aspects of records management and maintenance including: safe and secure storage, client access to records and to ensure that client records are not abandoned.

Expected Outcomes
Clients are satisfied that:

yy Processes exist to ensure acceptable record

keeping practices.

Resources

yy Physiotherapy Alberta. Practice Management

Record Keeping Checklist, 2011.

yy Physiotherapy Alberta. Privacy Guide for Alberta

Physiotherapists, 2008.

yy Office of the Information and Privacy

Commissioner of Alberta. www.oipc.ab.ca: Health Information Act Personal Information Protection Act Privacy Impact Assessment templates

yy Canadian Alliance of Physiotherapy Regulators.

Guidelines for the Collection, Maintenance, Transmission and Destruction of Electronic Health Information, 2009.

22. Legible means able to be read and deciphered. 23. This may include providing a reference source that explains the meaning of abbreviations, acronyms or diagrams or writing them out in full the first time used and bracketing the abbreviation. Reference sources may be part of policy and procedure manuals or kept so that they can be reproduced if required. 24. For many physiotherapists the relevant privacy acts are the Health Information Act and the Personal Information Protection Act however other legislation may be applicable depending on circumstances related to work environment and service delivery. Physiotherapy Albertas Privacy Guide for Alberta Physiotherapists provides a summary of relevant governing legislation and key recommendations for compliance. 25. In circumstances where retention periods are defined by legislation, the legislation will prevail. In circumstance where retention periods are greater than legislated requirements the physiotherapist may choose the longer retention period.

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Practice Management
Clinical, Financial and Equipment Maintenance Records
Records include health, financial, equipment management and practice related information. Physiotherapists must create and maintain clinical, financial and other practice management records to provide clients with ongoing access to their health information, to document the management of their physiotherapy practice and to ensure accountability for services delivered. All records created and maintained in the context of providing physiotherapy services are expected to meet the standards set out in Record Keeping and Management. collected by another practitioner and is still current, it need not be duplicated but should be referenced. 4. Chronological record of clients reason for referral, assessment, re-assessment and treatment including sufficient detail on care provided to enable client to be managed by another physiotherapist. At a minimum this will include: a. Clients reason for attendance. b. Date(s) of each professional interaction with client, including telephone or electronic contact. c. Dates of any cancelled or missed appointments and reason, where relevant. d. Assessment and/or evaluations performed on client and analysis of assessment results. In circumstances where the physiotherapist is basing components of their assessment on relevant assessment results of another practitioner, a copy of, or a reference to, the appropriate document should be included. e. Treatment plan and goals. f. Details of treatment provided including: i. Specific interventions including group treatment and their relevant parameters. ii. Client education. iii. Particulars of clinical or health advice provided, including telephone, fax or email advice relevant to clients condition. iv. Particulars of treatment(s) that was commenced but not completed, including reasons for non-completion. g. Results of each reassessment completed.

Physiotherapists demonstrate this standard by creating and maintaining records as follows:

Clinical records: Clinical records document client care history and include relevant health and related information needed to plan, deliver and monitor physiotherapy care. A physiotherapist providing or supervising physiotherapy services ensures that the clinical record documents clinical care and all professional interactions with clients. This includes care provided by physiotherapy support personnel. At a minimum, a clinical record must be created and maintained for each client that includes: 1. Clients demographic information including name (or other unique identifier), address, telephone number, birth date and gender. 2. Record of client referral information, as applicable, including: a. Reason for referral. b. Name and contact information of clients physician or other primary health provider, as relevant. 3. Clients relevant health, family and social history including results of consultations. In circumstances where this information has been

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h. Progress notes documenting client outcomes, how outcomes were measured, amendments to treatment plan resulting from outcomes, and reassessments or changes in clients condition. i. Discharge summary that includes the reason for ceasing treatment and, if applicable, other information including: i. Client status at discharge or the last time seen. ii. Goals and outcomes attained. iii. Recommendations given to client regarding self-management, prevention and further follow-up if required. j. Referrals made including name and contact information of consultant/facility referred to.

7. Copies of, or notes documenting, other forms of communications (e.g., email or telephone) in which relevant information was received or provided to the client or their authorised representatives or other health professionals involved in the clients care. Financial records: Financial records document the fees charged to the client for physiotherapy services and goods. In every circumstance in which a physiotherapist assesses or treats a client, renders any service, or sells or provides any product where a client or agency is billed for the service, a record is created that documents the financial transaction. At a minimum, financial records must include: 1. Clear identification of organization (name and address) and person(s) who provided product or service. 2. Clear identification of client to whom the services or product was provided (i.e., name and birth date, or a unique identifier). 3. Date product or service was provided. 4. Product or service details. 5. Fees charged for each service or product. 6. Date payment received and payment method. 7. When relevant, reason(s) why fee may have been reduced or waived. 8. If fee(s) charged to a third party, the full name and address of that third party. 9. Any interest charges. 10. Any balance due/owing. 11. Information documenting retaining an agency to collect an outstanding balance.

k. Results of consultations received. l. Discussions with other health providers involved in clients care.

m. Information, including name, on any aspect of client care assigned to physiotherapist support personnel. n. When providing treatment according to a care map, clinical pathway or similar plan, make reference to the specific plan and ensuring a copy of the plan and any updates to it are reasonably available and are retained for the same length of time as the record. 5. Evidence of client consent or consent from their authorised representative.26 6. Copies of all written communication or reports received from or provided to the client or their authorised representative or other health professional involved in the clients care.

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Clinical, Financial and Equipment Maintenance Records continued

12. Notations of all contact/correspondence with client or authorised representative on matter of fees is recorded in a legible, chronological format. Physiotherapy equipment maintenance records: Physiotherapists are required to ensure client safety by using equipment and machinery that is in good working condition. Equipment maintenance records provide accurate descriptions of the timing and nature of all inspections and servicing to equipment used in client care. At a minimum, equipment maintenance records must be kept27 that demonstrate: 1. Regular equipment inspection for cleanliness, functionality and defects. 2. Maintenance and servicing of every piece of equipment used in client care where there is potential to harm the client. 3. Any equipment defects and actions taken to remedy the defect. 4. Reprocessing and sterilization of reusable medical equipment detailing parameters to meet the requirements outlined in Alberta government reprocessing standards.

yy Their health and personal information is

confidential and secure.

yy They understand all particulars of fees charged

especially when services have been delivered by delegates and when interest charges are accruing on outstanding balances.

yy Upon request, they can access their health and

financial record in a reasonable time and for a reasonable fee, when a fee is charged.

yy Equipment and supplies used are appropriately

maintained, cleaned, disinfected and sterilized, or reprocessed.

Resources

yy Physiotherapy Alberta. Practice Management

Record Keeping Checklist, 2011.

yy Physiotherapy Alberta. Practice Guideline:

Informed Consent. 2008.

yy Physiotherapy Alberta, Infection Prevention and

Control Position Statement, 2008

yy Alberta Health and Wellness medical device

reprocessing standards and bulletins. www.health. alberta.ca/newsroom/pub-infection-prevention. html: Single Use Device Reprocessing Standards, January 2008. Reusable Medical Device Reprocessing Standards, January 2008.

Expected outcomes
Clients are satisfied that:

yy Their health record accurately reflects their

relevant physiotherapy history, care received and consent given.

26. Consent is an ongoing process of communication and therefore it should not be documented as a onetime event. 27. Within Alberta Health Service facilities, maintenance records may be maintained and stored by biomedical departments.

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Practice Management
Quality Improvement
Quality improvement refers to the processes and/ or programs that ensure services are safely and effectively delivered to clients, partners and others. These processes/programs range from routine collection and analysis of information about service, to more formal targeted initiatives with defined strategies and outcomes. Physiotherapists are responsible for engaging in quality improvement initiatives; however, specific activities undertaken will differ according to the physiotherapists role in the organization. e. Establishing, and/or participating in a process for managing, including, receiving and responding to client feedback and changing processes or service delivery if warranted. f. Complying with processes that involve gathering, analyzing and reporting data/ information related to physiotherapy service delivery and safety practices (e.g., safety audits).

Physiotherapists demonstrate this standard by:

1. Supporting a culture of ongoing learning and continuous improvement in physiotherapy service and client care. 2. Planning, conducting or participating in initiatives aimed at improving the delivery of physiotherapy services. Examples include but are not limited to: a. Assessing new research evidence for its applicability to clinical practice. b. Gathering and reviewing information related to clinical outcome measures. c. Comparing services with benchmark data, evidence and/or best practices. d. Undertaking new service initiatives.

3. Monitoring and evaluating the impact of implementation results of the quality improvement activities into clinical practice and/or work processes.

Expected outcomes
Clients are satisfied that:

yy There is evidence of a quality improvement

and patient safety culture.

yy Opportunity exists to provide feedback about

physiotherapy services.

Resources

yy Canadian Patient Safety Institute. Tools and

Resources www.patientsafetyinstitute.ca.

yy Health Quality Council of Alberta www.hqca.ca. yy Public Health Agency of Canada. Program
Evaluation Toolkit - www.phac-aspc.gc.ca/ php-psp/toolkit-eng.php.

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Appendix I
Glossary
Adverse event y An unexpected and undesired incident directly associated with client care or services. y An incident that occurs during the process of providing health and results in client injury or death. y An adverse outcome for a client, including an injury or complication - Safety Competencies Profile, Canadian Patient Safety Institute. y An event that results in unintended harm to the patient, and is related to the care and/or services provided to the patient rather than the patients underlying medical condition - Safety Competencies Profile, Canadian Patient Safety Institute. Assessment Includes, but is not limited to, examination of joint integrity and mobility, gait and balance, muscle performance, motor function, cardio respiratory function, pain, neuromotor and sensorimotor development, posture, cardiovascular and work capacity, cognition and mental status, skin condition, accessibility and environmental review - Essential Competency Profile for Physiotherapists in Canada 2009. Client A person, their legally authorized representative(s) or a group who requests, uses or receives professional services, products or information. A client may be an individual, family, guardian, group, agency, employer, or community. Client-centered service Client-centered service refers to an approach which recognizes the physiotherapists expertise and values the respect for and partnership with the people receiving physiotherapy care, including clients ability to make key choices in services delivered. In addition to clients individual needs, consideration is given to the environment or situation in which a person lives, works and plays Adapted from the Canadian Association of Occupational Therapists. Code of ethics

Statement encompassing a set of guiding principles and values reflecting the collective moral standpoint of a profession on which its practitioners are to rely.

Collaboration

A process where two or more people or organizations work together to achieve common goals by sharing knowledge, learning and building consensus (e.g., client, family and health professionals working toward common goals in clientcentered care).

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Competence/competency

The collection of knowledge, skills, attitudes and behaviors required by a physiotherapist during their professional career. Competency is the extent to which the physiotherapist successfully translates their knowledge, attitudes, skills and behaviors into service resulting in a valued difference to clients in a given environment.

Concurrent Conflict of interest

An act or occurrence happening at the same time. A situation that arises when the physiotherapist has a relationship or interest that may be seen as improperly influencing their professional judgment or ability to act in the best interest of the client.

Consent and informed consent

Consent involves receiving client or their legally authorised representatives permission to proceed with an agreed course of physiotherapy service. Consent may be revoked at any time. Informed consent requires clients to be given sufficient information to understand the nature of the proposed service, both initially and on an ongoing basis. Clients should receive information about the cost, nature, purpose, benefits, risks, alternative options and any other items as requested. Consent is only valid it the client has the capacity to understand the nature, purpose and consequences of the proposed treatment. If a client is unable to provide informed consent themselves then informed consent must be provided by the family member, legally authorised representative or guardian. If the client is a minor under 18, ideally consent should be obtained from the minor and their parent/legally authorized guardian. However, a mature minor under age 18 can consent to treatment independently if they understand the nature/purpose of the proposed treatment and consequences of receiving/refusing treatment. Consent can be written or oral, and may be expressed or implied. Having a written consent form does not mean there is informed consent. Informed consent involves ongoing communication between the parties involved.

Council

The governing body of the College of Physical Therapists of Alberta (which operates as Physiotherapy Alberta), elected in accordance with College bylaws.

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General register

List of all physiotherapists entitled to autonomously practice physiotherapy in Alberta. In Alberta, professional title is protected by law and only those listed on a College register can use the protected title and practice physiotherapy.

Guideline

A statement to assist with decisions about appropriate actions for specific circumstances. A clinical guideline is based on the best available evidence and provides recommendation for practice about specific clinical interventions for specific client populations.

Primary health care

A model of care involving health professionals working together and delivering care within the context of broader determinants that affect the health of individuals, families and their communities (e.g. education, environment and other socioeconomic factors). (Primary Healthcare, A Resource Guide for Physical Therapists, College of Physical Therapists of Alberta , 2007)

Provisional register

List of physiotherapists that hold a license to practice under certain restrictions. In Alberta, professional title is protected by law and only those listed on a College register can use the protected title and practice physiotherapy.

Related person

Person related by blood, marriage, partnership, adoption or a physiotherapy corporation in which a registrant or a related person has an interest.

Standard

A desired and achievable level of performance against which actual performance can be compared. (Canadian Council of Health Services Accreditation).

Standards of practice

An expectation reflecting general agreement on competent practice by the members of a recognized professional organization. Standards may be formally documented, approved or usual customary practice. Under the Health Professions Act, colleges must implement standards of practice.

Therapeutic relationship

The relationship that exists between a physiotherapist and a client during the course of physiotherapy treatment. The relationship is based on trust, respect and the expectation that the physiotherapist will establish and maintain the relationship according to professions standards of practice and code of ethics and will not harm or exploit the client in any way. (Adapted from Physiotherapy Albertas Therapeutic Relationships-Establishing and Maintaining Professional Boundaries 2007).

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Appendix II
Assignment of services: to support personnel under the supervision and direction of a physiotherapist
Tasks that may be assigned include: Tasks that may never been assigned include:

yy Participating in the collection of qualitative

and quantitative client data related to the clients physical status and functional ability.

yy Restricted activities authorised to

physiotherapists as included in the Government Organization Act.

yy Interpretation of referrals, diagnosis or

prognosis.

yy Performing selected objective measures/

tests/procedures.

yy Interpretation of assessment findings,

treatment procedures and treatment goals and the planning, development or modification of treatment plans.

yy Implementing therapeutic interventions

as assigned, this may include thermal, electrical and mechanical modalities or providing physical assistance (supporting or enhancing in nature) to clients.

yy Discussion of treatment rationale, clinical

findings and prognosis with client/family.

yy Reinforcing physiotherapists explanation

and providing verbal instructions to clients regarding treatment plans.

yy Documentation that should be completed

by a physiotherapist.

yy Helping physiotherapists evaluate the

effectiveness of specific interventions related to identified client outcomes.

yy Discharge planning. yy Any task or procedure requiring continuous

clinical judgment (i.e., any intervention containing an evaluative component that immediately influences clients treatment plan).

yy Documenting work performed including

the collection of workload measurement statistics as required.

yy Performing any task that contributes to a

safe and effective practice environment.

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Appendix III
Development of the Standards of Practice
The Standards of Practice for Alberta Physiotherapists were developed using the best available evidence, including information related to current practice, context and expert input. A targeted literature review was conducted to obtain information about the standards of practice currently in place for physiotherapists practicing in other parts of Canada. A review of international jurisdictions included: Australia, the United Kingdom, the United States, and the World Confederation of Physiotherapists. Practice standards for other Alberta health professions were also examined. A working group (comprised of physiotherapists with diverse expertise) appointed by Council provided input and feedback. Council reviewed and approved the draft standards before undertaking a validation with representatives and stakeholders from the physiotherapy community. Draft standards were circulated for comment in accordance with section 133 of the Health Professions Act. Feedback was considered and the standards were again reviewed by Council for final approval prior to publication. Two focus groups were conducted involving eighteen physiotherapists from the Edmonton area. Representatives came from both public and private practice sector and worked in academic, regional health authority administration, acute, tertiary, and home care centres, geriatric day and school based programs. Feedback was obtained and considered in the preparation of the final standards document.

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www.physiotherapyalberta.ca
300, 10357 - 109 Street, Edmonton, Alberta T5J 1N3 T 780.438.0338 | TF 1.800.291.2782 | 780.436.1908 info@physiotherapyalberta.ca

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