The Chartered Society of Physiotherapy The Chartered Society of Physiotherapy


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Criteria: Consent

5.1 Members obtain and document the service user’s informed consent before any advice, assessment, examination, intervention, treatment or procedure


5.1.1 The service user’s consent is obtained and documented before giving advice or beginning an assessment, examination, intervention, treatment or procedure

5.1.2 The consent process includes:

  • A: consideration of the service user’s age, capacity to consent, emotional state and cognitive ability
  • B: discussion of treatment options, including significant benefits, risks side effects and alternatives to proposed intervention
  • C: opportunity for the service user to ask questions
  • D: establishing the service user’s consent or otherwise to sharing information to others directly involved in their care
  • E: informing the service user of their right to decline physiotherapy at any stage
  • F: specific recording in the notes when a service user declines physiotherapy, including a note as to the service user’s rationale for the decision if known
  • G: informing the service user that their physiotherapy may be observed or delivered by another healthcare professional/ student
  • H: giving the service user the opportunity to decline observation of their physiotherapy or treatment by another healthcare professional confidentially
  • I: provision of written information, where possible, to assist in the consent process

5.1.3 Where written information/ leaflets are used this is documented in the notes

5.1.4 Versions of written information/ leaflets are stored in line with legislation for the retention of medical records

5.1.5 There are  policies for the consent process which include:

  • A: induction and training in gaining consent
  • B: indications of appropriate situations for the delegation of the gaining of consent
  • C: members undertake the delegated task of gaining service user’s consent only when it is appropriate to do so
  • D: those interventions requiring written consent forms
  • E: situations where the service user  declines  treatment by a student or support worker
  • F: safeguarding children
  • G: safeguarding vulnerable adults
  • H: situations where a formal assessment of capacity may need to be made by an appropriate practitioner

5.2 Where written consent is obtained, a copy of the consent record is included in the service user’s records


5.2.1 A policy is in place detailing those physiotherapy procedures where written consent is to be obtained

5.2.2 Where written consent is gained, a copy is retained in the service user’s records and a copy is given to the service user

5.3 Where a service user lacks capacity to consent for themselves the appropriate process is in place to allow a ‘best interests decision’ to be made under the relevant Mental Health In/Capacity Acts


5.3.1 There are polices in place for identifying when a service user may lack the capacity to give consent for treatment themselves

5.3.2 Qualified members are aware of the process for invoking the relevant Mental Health or In/Capacity Act where a service user lacks the capacity to give consent for themselves

5.3.3 Where consent is gained by the service user’s advocate under the relevant Mental Health or In/Capacity legislation, a record is retained in the service user’s records

5.3.4 Where a valid Lasting Power of Attorney (LPOA) is in place its directions are followed

5.3.5 Where there is a valid advanced directive its directions are followed


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