The Chartered Society of Physiotherapy The Chartered Society of Physiotherapy

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Criteria: Physiotherapy management and treatment

8.1 There is fair and equitable access to physiotherapy services according to need

Criteria

8.1.1 There is evidence within the organisation of

  1. stakeholder engagement specifically to support the planning and design of services
  2. access routes to physiotherapy services being promoted to all referrers and appropriate service user groups or within appropriate service user environments
  3. transparent and ethical protocols governing waiting list management and the prioritisation of service users
  4. service features which support service user’s choice; these may include for example appointment times or place of treatment
  5. a clearly communicated procedure for managing referrals which have not been seen within a locally agreed time-scale
  6. protocols that ensure effective and appropriate discharge arrangements

Standard 8.2 There is a system to ensure that physiotherapy care is based on the best available evidence of effectiveness

Criteria

8.2.1 Members;

  1. actively engage with the evidence base through critical appraisal of available evidence
  2. have access to;
  • library and library search facilities
  • internet facilities

8.2.2 There are systems in place;

  1. for disseminating information about effective practice 
  2. for providing links with external agencies to identify good practice
  3. to demonstrate implementation of evidence-based clinical guidelines and the use of research evidence
  4. that support the integration of research activity within day-to-day practice
  5. that enable and encourage members to develop evidence and to share their research findings through appropriate channels

Standard 8.3 Appropriate information relating to the service user and the presenting problem is collected

Criteria

8.3.1 Where appropriate, standardised datasets are in use that facilitate benchmarking of data and respond to national good practice initiatives and requirements

8.3.2 There is evidence that information is collected to inform the physiotherapeutic process which, where appropriate, includes:

  1. the service user’s demographic details
  2. presenting condition/problems
  3. history of the presenting condition including management of the problem to date
  4. the service user’s perception of their needs
  5. the service user’s expectations of intervention
  6. past medical history
  7. current medication/treatment
  8. contra-indications/precautions/allergies/red flags
  9. social and family history/lifestyle
  10. documentation and evaluation of relevant clinical investigations/results to assist the diagnosis and management process

8.3.3 There is written evidence of a physical examination carried out including measurable data which includes:

  1. observation
  2. use of specific assessment tools/techniques
  3. handling/palpation

8.3.5 Where the required information is missing or unavailable, the reasons are documented

8.3.6 Appropriate outcome measures are identified and implemented at assessment including, where possible and appropriate;

  1. one recommended condition/disease specific patient (service user)  reported outcome measures (PROM)
  2. one disease specific performance measure (clinical outcome measure)
  3. one patient (service user) reported experience measure (PREM)

8.4 Analysis is undertaken following information gathering and assessment in order to formulate a treatment plan, based on the best available evidence

Criteria

8.4.1 There is consideration and critical evaluation of information about effective interventions relating to the presenting condition

8.4.2 There is evidence of a clinical reasoning process with identified needs/problems, formulated from the information gathered

8.4.3 A working hypothesis/diagnosis is formed, with relevant signs and symptoms recorded

8.4.4 The clinical impression is documented and discussed with the service user

8.4.5 Subjective markers are agreed with the service user

8.4.6 Objective markers are agreed with the service user

8.4.7 Analysis is undertaken following information gathering and assessment in order to formulate a plan for intervention, based on the best available evidence

8.4.8 Where there is no intervention indicated, this information is relayed to the referrer, where there is one

8.4.9 Information relating to options for intervention is identified, based on the best available evidence, in order to deliver effective care

8.4.4 The findings of the clinical assessment are explained to the service user.

8.5 Appropriate treatment options are identified, based on the best available evidence, in order to deliver effective care.

Criteria

8.5.1 Clinical reasoning is recorded that explains why a specific approach has been implemented.

8.5.2 The service user is enabled to make an informed choice about their care, based on the best available evidence on effective and appropriate interventions

8.5.3 Goals are agreed with the service user, multidisciplinary team including outside agencies and wider carers and family

8.5.4 Where clinical guidelines or local protocols are used this is recorded in the records

8.5.5 A treatment plan is included in the physiotherapy record

8.5.6 All interventions are implemented according to the treatment plan

8.5.7 Members contribute to the development of evidence by gathering information throughout the treatment of service users

8.5.8 All advice/information given to the service user is recorded, signed and dated.

8.5.9 A record is made of medical devices loaned and issued to the service user

8.5.10 When it is in the best interest of the service user a referral is made to another professional and the reasons discussed with the service user

8.6 The plan for intervention is constantly evaluated to ensure that it is effective and relevant to the service user’s changing circumstances and health status

Criteria

8.6.1 At each treatment session there is a review of:

  1. the treatment plan
  2. subjective markers
  3. objective markers
  4. results of relevant investigations.

8.6.2 All relevant changes, subjective and objective, are documented.

8.6.3 Any changes to the intended plan are recorded in the record with the reasons given

8.6.4 Any changes to the treatment plan are documented

8.6.5 Outcome is measured as appropriate to each indicator to assess the effect of intervention

8.6.6 Information derived from the use of outcome measures is shared with the service user

8.6.7 Adverse and unexpected effects occurring during treatment are reported and evaluated using the relevant mechanisms

8.7 On completion of the treatment plan, arrangements are made for discharge or transfer of care

Criteria

8.7.1 The service user is involved with the arrangements for their transfer of care/discharge and offered copies of transfer or discharge summaries

8.7.2 Arrangements for the transfer of care/discharge are recorded in the record

8.7.3 When the care of a service user is transferred, information is relayed to those involved in their on-going care in the most appropriate manner and format

8.7.4 A discharge summary is sent to the referrer upon completion of the episode of care in keeping with agreed local policies

8.7.5 Where service user’s information is transferred this meets the requirements of consent, confidentiality and disclosure

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