Guide:
Assessment, Diagnosis, Treatment Standard

Standardized measures are tools used to objectively assess the outcome of an intervention. They are designed for specific purposes in different populations, with guidelines on administration, scoring, interpretation, and psychometric properties.

“Psychometric properties” refers to how well a tool works – whether it measures what it should (validity), gives consistent results (reliability), and detects changes over time (responsiveness). When a tool meets these criteria, you can be confident in its results.

Examples include using a goniometer to measure range of motion or a sit-to-stand test to assess functional movement.

These tools are essential in physiotherapy because they:

• Provide objective and repeatable data, which ensures consistency and reliability in evaluating outcomes and tracking progress over time.
• Support clinical decision-making and prognosis by allowing for comparisons with population norms or similar patient cases.
• Facilitate communication and collaboration among health-care providers by providing clear, numeric data that facilitates the sharing of patient information.

Standardized measures are often developed and validated through research, meaning they have evidence supporting their reliability and validity. By using these tools, you ensure that your assessments are grounded in best practices, which increases the likelihood of effective treatment plans.

When referring patients to other health-care providers, the goal is to ensure timely, appropriate, and coordinated care. Start by confirming that the referral is necessary and that the provider’s scope of practice matches the patient’s needs. If you’re unsure, consult with colleagues and familiarize yourself with local resources.

Communicate clearly with the patient about why the referral is being made, what they can expect, and obtain consent to share relevant health information. Provide the receiving provider with complete and accurate documentation in a timely manner to support the transition.

To ensure continuity of care, follow up as needed with both the patient and the other provider, clarify next steps as part of the treatment plan, and keep thorough records of all outcomes.

Many conditions benefit from a collaborative approach, which can be challenging in private or community settings. Take time to build a network of trusted health-care providers and resources in your area.

By law, you must obtain informed consent from your patients. When a patient cannot provide consent, a substitute decision-maker must be identified according to the hierarchy of substitute decision-makers. Ongoing informed consent means ensuring that consent remains valid and appropriate throughout the entire course of care, not just at the start.

Consent may be given verbally, in writing, or implied through a patient’s actions, such as offering their arm for an examination.

Consent may reasonably persist over time when the treatment plan, risks, and patient circumstances remain unchanged. However, the need to check in increases as time goes on, especially when:

• There are significant gaps between appointments,
• The treatment plan evolves or new techniques are introduced,
• There is a material change in the patient’s condition, goals, or expected outcomes, or
• Other health-care providers become involved in the care, such as physiotherapist assistants or students.

To maintain ongoing informed consent:

• Explain the treatment, its benefits, risks, and alternatives, and any potential consequences of not proceeding each time there is a meaningful change.
• Communicate clearly in a way that allows patients to understand. Take the time to answer their questions.
• Check in regularly to confirm the patient still understands and agrees to the plan.
• Respect the patient’s right to refuse or withdraw consent at any stage.
• Document all relevant discussions and decisions about consent to ensure transparency and continuity of care.

For more information, please refer to the College’s resource on Consent.

The term “physical examination” in the standard doesn’t necessarily mean the examination must be conducted through physical touch or in-person contact.

It really refers to a bodily examination — that is, an examination of the patient’s body that is relevant to the symptoms they are presenting. This might include a visual inspection, observations of movement, or other methods that allow you to evaluate a patient’s physical function by examining their body.

You can conduct a bodily examination either in-person or virtually. You may also engage a physiotherapist assistant to assist the patient during the assessment, if appropriate. Use your professional judgement to decide whether your chosen method is appropriate for your patient and gives you the information you need about their health status.

Achieving patient self-management begins with setting meaningful, patient-centered goals from the onset of care. This starts during the assessment, where it’s important to understand the patient’s needs and ensure that physiotherapy goals are SMART (Specific, Measurable, Achievable, Relevant, Time-bound). Encourage self-management from the beginning and continue to foster it throughout the treatment process, empowering the patient to take an active role in their care from day one.