Policies and Procedures Checklist

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This table is a summary of some of the standards and rules that apply when providing care in settings such as home care, private practice or a mobile practice and is designed to assist you when opening a practice. It is not meant to replace your review of the full standards.

Name of PolicyWhat is it? Required to be written? Required
for QA Assessment? 
Examples of what should be includedRelated Resources
Privacy
How you will ensure privacy/keep patient personal health information safeYes — Personal Health Information Protection Act (PHIPA), 16(1)
NoWho is the Health Information Custodian (HIC)

How personal health information will be safeguarded

How to access a copy of a health record

What to do in case of a privacy breach
A Guide to PHIPA — Form 1: Sample Written Public Statement, page 28

Privacy Management Handbook for Small Health Care Organizations
Management of Adverse Events and Patient Safety ConcernsHow to manage adverse events that may occur because of controlled acts you are rostered for

How to manage safety events that could happen in your clinic
Yes — Controlled Acts and Restricted Activities requires a management plan for any adverse events related to the rostered activity

A management plan for general patient safety concerns is recommended, but not required
Yes, but only the management plan for adverse events linked to rostered activitiesHow you will manage adverse events that could occur as a result of a controlled act — e.g. spinal manipulation

What to do if a patient sustains a burn

How to manage a slip and fall in your clinic
Risk Management Resource: Patient Safety
 
Adverse Events Rostered Activities
QA Checklist

 
Critical Incident Reports
Infection Control

The infection control policies for your workplace


 
No, but recommended — Infection Control Standard

What is the cleaning schedule

What types of PPE (personal protective equipment) are to be worn

Are patients screened for active viral symptoms
IPAC Guidelines — Performing a Risk Assessment

Public Health Ontario — Routine Practice Factsheet 
Equipment Maintenance


 

How equipment is inspected and maintained for patient safetyNo, but recommended — Risk Management and Safety StandardWhat is the schedule for modalities to be serviced

Where are equipment service manuals found

A record of when equipment is maintained and what is done
Equipment Maintenance FAQs 
Communication Plan for Physiotherapist Assistants (PTAs)




The plan for communication between the PTA and the supervising physiotherapistYes —
Supervision Standard
YesHow and when the PT will discuss patient care with the physiotherapist assistant 

How the PTA can contact the physiotherapist 

How the PTA can contact the alternate supervisor if the physiotherapist cannot be reached 
Sample Written Communication Protocols
 
PTA Communication Plan QA checklist
Billing Review




 
Method the physiotherapist will use to review the accuracy of billing that uses their registration numberNo, but recommended — Funding, Fees and Billing StandardNoThis review process should ensure that: 
Any fees charged are accurate and reasonable 

Billings or accounts are accurate 
Create a Process for Reviewing Your Billing
Fee Schedule




A written list of all services offered at workplace and their costsYes — Funding, Fees and Billing StandardNoThe Fee Schedule must include the cost of: 
• Assessment and treatment fees
• Reports and fees for copies of patient records
• Equipment and any additional fees
• Fees and policies related to bundled physiotherapy services
• Cancellation or late fees and interest charges
Refund policies
Funding, Fees and Billing Resources