Q. Am I required to co-sign patient records of the individuals I supervise?
A. There is no legislated requirement to co-sign patient records. The act of co-signing a chart is linked to your responsibility to supervise.
If you co-sign notes, you must remember that simply reading a chart note is insufficient to satisfy your responsibility. You have the additional duty to ensure that the diagnosis and treatment described is reasonable in the circumstances. Your signature (or electronic signature) on a patient record demonstrates that you have both reviewed the note and that you agree with the appropriateness of the treatment plan.12
Before deciding to co-sign a chart, be sure that you can verify the assessment findings and therefore the appropriateness of the treatment plan. If you were not present throughout the assessment or treatment session you may not be able to do so.
Q. Do I need to be on-site at all times when providing supervision?
A. The purpose of supervision is to ensure the delivery of safe, quality physiotherapy service. Some aspects of effective supervision require that you, as the supervising physiotherapist, are on-site and accessible. For example, you must be on-site initially to observe the supervisee’s performance and determine their level of competence, when the supervisee is learning a new skill, to conduct supervisee evaluations, anytime you have concerns about the supervisee’s performance, and any time a physiotherapist intern under your supervision is performing a basic restricted activity, or when a physiotherapist student is practicing any restricted activity (basic or advanced).7
Always ask yourself this: How will I know if the supervisee is competent to do what is assigned at any given time?
Once you have determined the supervisee is competent and performing at an acceptable level, you may be able to provide indirect supervision for interventions other than restricted activities.
Q. Can I bill for treatment provided by a supervisee under my registration number?
A. Physiotherapy Alberta’s Fees and Billing Standard of Practice13 clearly states that all billing records need to be transparent and verifiable including who has been involved in delivering the service and what the related fees are. When it comes to billing for treatment provided by a supervisee, the answer depends on the type of supervisee.
Physiotherapist interns are regulated members and therefore should submit bills using their own registration numbers.
Support workers are required to work under your supervision. You are accountable to ensure that your registration number is used appropriately for billing. To ethically bill for services provided by a support worker under your registration number, you must also be actively involved in the patient’s care.
When services are provided by student physiotherapists, keep the following considerations in mind: the patient must consent to being treated by a student physiotherapist,3 the patient must be aware of any fees that will be billed for services,13 and you are actively involved in the patient’s care. You are accountable for how your registration number is used.
It is important to remember that payers have their own policies related to what they will or will not pay for under extended health benefits.
Q. Can support workers complete outcome measures?
A. It is up to you, the supervisor, to determine what is assigned. This task assignment can include the completion of measurement or rating activities if you have determined that the supervisee is competent to complete the task accurately. It is your responsibility to interpret the outcome measure and determine how treatment will be modified in light of the outcome.3
Q. Which restricted activities can I assign to supervisees?
A. Basic restricted activities can be completed by physiotherapist interns and physiotherapist students but always under your direct supervision and only if you are competent to complete the activity.2
Physiotherapist interns are not allowed to perform advanced restricted activities under any circumstances.2
At no time should support workers be assigned any aspect or component of a restricted activity.3
Q. How many physiotherapist interns, support workers or physiotherapist students am I allowed to supervise at one time?
A. Physiotherapy Alberta does not specify a limit to the number of students/interns/support workers you can supervise at one time. However, it is your responsibility to provide adequate supervision to meet Physiotherapy Alberta’s Supervision Standard of Practice.7 Failure to properly supervise can put the public at risk. Only agree to supervise the number of students, interns or support workers you can actually supervise adequately. If pressured to supervise more than you are able, it is important to remember that Physiotherapy Alberta standards for supervision must take priority over the demands of employers.
Q. What are my responsibilities as a physiotherapist when I supervise a support worker who provides both physiotherapy and occupational therapy functions for a shared patient?
A. You are responsible for supervising support workers if and when they perform physiotherapy tasks that you have assigned to them. Because physiotherapists and occupational therapists have overlapping scope of practice and competencies, it is prudent that both support workers and patients clearly understand which part of their overall rehabilitation treatment is physiotherapy (for which you are responsible).7
In addition, the Concurrent Treatment Standard of Practice14 requires that you collaborate with the occupational therapist to coordinate the support worker’s assignment and the care provided to the patient.
Q. Do the requirements to supervise support workers differ in different patient care settings?
A. No. In any active treatment model where you assign components of the physiotherapy treatment program to support workers, you must provide appropriate supervision considering the patient’s best interests, the support worker’s competence and performance and what is reasonable considering the service delivery model.7
In a consultative model of care, you may be providing consulting services rather than acting as a supervisor. In this case, you are accountable for the consultation and its recommendations but not the services provided by the staff of the employer to whom the consultation was provided. You are accountable to ensure your employer is aware of this. An example would be if a physiotherapist provided consultation to a group home about stretches for a client with spasticity and taught the group home staff how to perform the stretches with the client. The physiotherapist would be responsible for the consultation, education and information given to the group home about circumstances when they should re-contact the consultant but not for the supervision of the group home staff.
Q. What about consent? Who needs to obtain consent for a supervisee to see a patient?
A. It is the responsibility of the most responsible physiotherapist providing treatment to obtain consent. You must ensure that the patient consents to being treated by a support worker or physiotherapist student. You may assign the physiotherapist student the responsibility to obtain consent, but you must ensure that consent is obtained. The supervisee should reconfirm this consent at the start of a treatment session.
Physiotherapist interns, as regulated members, are responsible to obtain their own consent.6
Q. What are my responsibilities when I share supervision responsibilities with another physiotherapist?
A. When two or more physiotherapists share supervision responsibilities, it is ideal that they communicate and collaborate in developing and refining the supervision plan with the supervisee. A clear understanding of the working relationships and responsibilities, understood by all parties, will not only provide clear direction for the supervisee but will support effective supervision.
In the case of physiotherapist interns, the supervisee must have formal, signed supervisory agreements with both supervisors.4
Q. What if I am going to be away for a brief period of time, unexpectedly or otherwise?
A. The answer varies depending on many factors, including the phase of supervision, your assessment of the supervisee’s qualifications and experience, your assessment of the supervisee’s competence, the practice setting and the duration of the absence. The general principle is that physiotherapy services must be either performed by or supervised by a member who is on the General Register.i
Once the direct supervision phase has been completed, there are many ways for you to meet your supervision responsibilities without being physically present. For example, you could complete a caseload review discussion with the supervisee and discuss the supervisee’s care plan for patients prior to and following a brief planned absence. You must also identify a regulated member whom the supervisee could contact in the event of an unanticipated problem during your absence.
If, however, there are supervisee performance concerns or a prolonged absence, an alternate supervision arrangement is required.7 If the supervisee is a physiotherapist intern, you will need to notify Physiotherapy Alberta that you are unable to continue the supervision agreement, and the physiotherapist intern will need to submit a new supervision agreement for approval.
Q. What aspects of supervision should be documented in the patient record?
A. In addition to having a supervision plan that describes how the supervisor will provide supervision and the progression of that supervision, certain aspects of the supervised practice should be documented on the patient record. For example, when a patient provides consent to be treated by a supervisee, the consent should be documented. In addition, when a physiotherapist assigns tasks to a support worker or physiotherapy student the tasks assigned, and parameters of treatment must also be documented. The support worker or physiotherapy student should also be made aware of any patient outcomes that would indicate a need for urgent re-evaluation by the physiotherapist.
- When physiotherapy interns are supervising support workers, the intern’s supervising physiotherapist is ultimately responsible for the intern’s assignment of services to the support worker, thereby meeting this requirement.