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Audit tool: Physiotherapy management and treatment

Details for quality assurance in management and treatment can be found below. Please download the audit tool from the bottom of the page.

Part 1A: Data collection from patient records

There is evidence that standardised datasets are used

There is evidence that the following information is collected

  • The service user’s demographic details
  • Presenting condition/problems
  • History of the presenting condition including management of the problem to date
  • The service user’s perception of their needs
  • The service user’s expectations of intervention
  • Past medical history
  • Current medication/treatment
  • Contra-indications/precautions/allergies/red flags
  • Social and family history/lifestyle
  • Documentation and evaluation of relevant clinical investigations/results to assist the diagnosis and management process

There is written evidence of a physical examination carried out including

  • Observation
  • Use of specific assessment tools/techniques
  • Handling/palpation
  • Where the required information is missing or unavailable, the reasons are documented 

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

  • One recommended condition/disease specific patient (service user) reported outcome measures (PROM)
  • One disease specific performance measure (clinical outcome measure)
  • One patient (service user) reported experience measure (PREM)

There is evidence that analysis is undertaken following information gathering and assessment in order to formulate a treatment plan, based on the best available evidence which includes

  • Consideration and critical evaluation of information about effective interventions relating to the presenting condition
  • Evidence of a clinical reasoning process with identified needs/problems, formulated from the information gathered
  • A working hypothesis/diagnosis formed, with relevant signs and symptoms recorded
  • The clinical impression documented and discussed with the service user
  • Subjective markers agreed with the service user
  • Objective markers agreed with the service user
  • Analysis is undertaken following information gathering and assessment in order to formulate a plan for intervention, based on the best available evidence
  • Where there is no intervention indicated, this information is relayed to the referrer, where there is one
  • Information relating to options for intervention is identified, based on the best available evidence, in order to deliver effective care
  • The findings of the clinical assessment are explained to the service user. 

There is evidence that appropriate treatment options are identified, based on the best available evidence, in order to deliver effective care which includes

  • Recording clinical reasoning that explains why a specific approach has been implemented
  • Enabling the service user to make an informed choice about their care, based on the best available evidence on effective and appropriate interventions
  • Agreement of goals are agreed with the service user, multidisciplinary team including outside agencies and wider carers and family
  • Where clinical guidelines or local protocols are used this is recorded in the records
  • A treatment plan is included in the physiotherapy record
  • All interventions are implemented according to the treatment plan
  • All advice/information given to the service user is recorded, signed and dated
  • A record is made of medical devices loaned and issued to the service user
  • 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 

There is evidence that 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 to include

  • At each treatment session there is a review of:

a. the treatment planb. subjective markersc. objective markersd. results of relevant investigations

  • Documentation of all relevant changes, subjective and objective
  • Changes to the intended plan are recorded in the record with the reasons given
  • Changes to the treatment plan are documented
  • Outcome is measured as appropriate to each indicator to assess the effect of intervention
  • Information derived from the use of outcome measures is shared with the service user
  • Adverse and unexpected effects occurring during treatment are reported and evaluated using the relevant mechanisms

There is evidence that on completion of the treatment plan, arrangements are made for discharge or transfer of care including

  • The service user is involved with the arrangements for their transfer of care/discharge and offered copies of transfer or discharge summaries
  • Arrangements for the transfer of care/discharge are recorded
  • 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
  • A discharge summary is sent to the referrer upon completion of the episode of care in keeping with agreed local policies
  • Where service user’s information is transferred this meets the requirements of consent, confidentiality and disclosure

Part 1B: Data collection from organisational policies and procedures

There are organisational policies and procedures to ensure fair and equitable access to physiotherapy services according to need including

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

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

Members active engagement with the evidence base through critical appraisal of available evidence

Members having access to

  • library and library search facilities
  • internet facilities 

Systems in place

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

There are policies in place to ensure appropriate information relating to the service user and the presenting problem is collected including:

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

Information collected to include:

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

Written evidence of a physical examination carried out including measurable data which includes:

  • observation
  • use of specific assessment tools/techniques
  • handling/palpation 

Procedures where the required information is missing or unavailable, the reasons are documented Identif Identification and implementation of appropriate outcome measures including, where possible and appropriate:

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

There are policies in place to ensure analysis is undertaken following information gathering and assessment in order to formulate a treatment plan, based on the best available evidence including:

  • Consideration and critical evaluation of information about effective interventions relating to the presenting condition
  • Evidence of a clinical reasoning process with identified needs/problems, formulated from the information gathered
  • Formation of a working hypothesis/diagnosis is formed, with relevant signs and symptoms recorded
  • Documentation of the clinical impression and discussion with the service user
  • Agreement of the subjective markers with the service user
  • Agreement of the objective markers with the service user
  • Analysis following information gathering and assessment in order to formulate a plan for intervention, based on the best available evidence
  • Where there is no intervention indicated, this information is relayed to the referrer, where there is one
  • Information relating to options for intervention is identified, based on the best available evidence, in order to deliver effective care
  • The findings of the clinical assessment are explained to the service user 

There are policies and procedures to ensure that appropriate treatment options are identified, based on the best available evidence, in order to deliver effective care including

  • Clinical reasoning is recorded that explains why a specific approach has been implemented
  • The service user is enabled to make an informed choice about their care, based on the best available evidence on effective and appropriate interventions
  • Goals are agreed with the service user, multidisciplinary team including outside agencies and wider carers and family
  • Where clinical guidelines or local protocols are used this is recorded in the records
  • A treatment plan is included in the physiotherapy record
  • All interventions are implemented according to the treatment plan
  • Members contribute to the development of evidence by gathering information throughout the treatment of service users
  • All advice/information given to the service user is recorded, signed and dated
  • A record is made of medical devices loaned and issued to the service user
  • 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 

There are policies and procedures to ensure that 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 including:

  • At each treatment session there is a review of:

A: the treatment planB: subjective markersC: objective markersd: results of relevant investigations

  • All relevant changes, subjective and objective, are documented
  • Any changes to the intended plan are recorded in the record with the reasons given
  • Any changes to the treatment plan are documented
  • Outcome is measured as appropriate to each indicator to assess the effect of intervention
  • Information derived from the use of outcome measures is shared with the service user
  • Adverse and unexpected effects occurring during treatment are reported and evaluated using the relevant mechanisms 

There are policies and procedures to ensure that on completion of the treatment plan, arrangements are made for discharge or transfer of care including

  • The service user is involved with the arrangements for their transfer of care/discharge and offered copies of transfer or discharge summaries
  • Arrangements for the transfer of care/discharge are recorded in the record
  • 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
  • A discharge summary is sent to the referrer upon completion of the episode of care in keeping with agreed local policies
  • Where service user’s information is transferred this meets the requirements of consent, confidentiality and disclosure

Part 2: Service user feedback

  • I was given a choice of times for physiotherapy or location where possible
  • I was given the opportunity to provide information to help plan my care
  • I was able to discuss what I hoped to achieve with physiotherapy
  • I was given the opportunity to discuss my physiotherapy- related problems
  • I was able to discuss the plans for my physiotherapy
  • At the end of physiotherapy I was able to discuss my discharge

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