Registered health professionals are accountable for the care of their patients; they remain professionally accountable for the appropriateness of any delegated duties and acts or omissions of care undertaken by students or support workers who they are supervising.
They also remain professionally accountable for the quality of record keeping entries undertaken by students and support workers, in respect of delegated duties relating to their patients.
There is no explicit direction from the HCPC regarding when or if the physiotherapist who has delegated tasks to a support worker or undergraduate student should countersign their respective entries to the health record.
- You are responsible for the appropriateness of your decision to delegate a task
- Whenever you give tasks to another person to carry out on your behalf, you must be sure that they have the knowledge, skills and experience to carry out the tasks safely and effectively. You must not ask them to do work which is outside their scope of practice
For many physiotherapists, the decision to delegate tasks will be governed by a combination of national and local policy on the delivery of care across a patient pathway utilising skill mix.
Physiotherapists will also be governed by local employer policy on delegation and supervision of students and support workers.
Health record entries: support workers
The qualified physiotherapist remains accountable for the management of a patient’s physiotherapy needs at all times, although the management of some patients may be delegated to appropriately trained support workers, either by the physiotherapist themselves, or by the existence of an organisational policy that defines which groups of patients may have part of their care delivered solely by support workers.
National or local policy may dictate the approach physiotherapists must take in relation to delegation of tasks to support workers. In the absence of such a policy, the CSP advises that:
- If the physiotherapist is delegating tasks to support workers, the decision to delegate should be recorded in the records. Thereafter, the records made by the support worker to document their intervention do not need to be countersigned. The physiotherapist should only countersign where an event occurs which changes the overall patient management plan such that the support worker needs further direction from the physiotherapist
- If the organisation delegates aspects of the care pathway for groups of patients solely to the support worker no countersignature is needed, provided that the activities are performed within the context of a formal written policy and care pathway that clearly states that individual patients may be managed solely by a support worker if the patient fits the overall care pathway that is managed by the support worker
Health record entries: undergraduate students
- You have a duty to make sure, as far as possible, that records completed by students under your supervision are clearly written, accurate and appropriate
The practice educator, physiotherapist or qualified member of the multidisciplinary team is responsible for the patient and professionally accountable for the actions of the student, who is performing delegated tasks.
The person who is responsible for the care of the patient must provide the countersignature.
Students will often make notes in a notebook to support their learning. It is important to ensure that these notebooks do not contain any patient identifiable information.
Students should discuss any support requirements in relation to record keeping with the practice educator and university so that reasonable adjustments are made to ensure the notes reach the required standard.
Delegation and supervision policy for students
If no delegation/supervision policy or record keeping policy exists that is specific about countersignatures relating to student entries to the health record, it is good practice to establish one (bearing in mind HCPC guidance on this) which should address the following issues:
- How the practice educator will ensure the student is competent to carry out the delegated tasks safely and effectively (for example, by documenting the training given and how their competency has been tested)
- What level of supervision the practice educator deems appropriate for the setting in which the student is working and for the tasks they are undertaking (for example, direct observation, out of sight but with follow-up discussion, etc)
- How students and their supervisors review entries to health records to ensure the entries are accurate and reflect the interaction with the patient
- What the countersignature signifies; for example, does it convey that the supervisor has observed the student undertaking the delegated task with the patient (this is not a mandatory approach), or does it signify that the student’s work regarding the delegated task has subsequently been reviewed and discussed between the student and supervisor, and the supervisor is approving of the student’s actions? The latter is acceptable, if there is a robust system in place for checking competence regularly (including, if appropriate, knowledge of child/vulnerable adult procedures)
- The student must understand that he/she should ask for help immediately if it is needed (this does not just cover clinical support). For example, if the patient starts to indicate unrealistic expectations or behaves in such a way as to call into question mental capacity etc, then the delegator must be open to requests for assistance in reality rather than in theory
Access to and use of record keeping systems by students
So that students on clinical placement are able to access and input to record keeping systems from the start of their placement, the university’s practice education coordinator and the practice educator should plan ahead. They should consider and address the following issues:
- Does the placement provider require the student to have an ‘honorary contract’ in place before they can work with patients and input to relevant health records?
- Does the placement provider use an electronic system to manage health records, and if so, does the student need to be supplied with a password, smartcard, or other access/authentication device to enable them to make entries in health records?
- Does the placement provider need to be supplied with a photograph of the student for a smartcard, or carry out an identification check before issuing login details for the record keeping system, and how long does this take to organise?
- What training must be provided for the student on how to use the provider’s electronic or paper record keeping system, and how will this be organised and delivered?
- Will the student need to return any smartcard or other access device at the end of placement, or to keep it if they will be returning to the placement provider?
In the electronic record keeping environment, procedures are being put in place to give appropriate access to health records and to ensure that student contributions are clearly labelled within the health record.
However some systems are not yet configured to allow student access and input of data. In such circumstances, common practice is for the responsible staff member to input into the record on behalf of the student, noting that the work was actually delegated to the named student so that this is clearly flagged in the record.
Health record entries: physiotherapists undertaking post graduate training and/or returning to work
HCPC registered physiotherapists (whether undertaking postgraduate studies or returning to practice after a career break) do not need to have their entries into the health record countersigned.
Physiotherapists undergoing a formal return-to-work programme who are not yet HCPC registered must have his or her records countersigned, as they have not yet fulfilled the requirements of autonomous practice associated with HCPC registration.