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Controlled Acts and Restricted Activities

A controlled act is a healthcare activity that can cause harm if a person who is not qualified or skilled performs it.

There are 14 controlled acts listed in the Regulated Health Professions Act (RHPA). The RHPA also outlines which activities can be performed by each of the regulated health care professions.

Be sure to look at the College’s Controlled Acts and Restricted Activities Standard. 

There are seven controlled acts (sometimes referred to as authorized activities) that Ontario PTs can perform. A physiotherapist must roster (complete an online declaration) with the College if they perform any of the following controlled acts.

• Spinal manipulation
• Tracheal suctioning
• Acupuncture (this includes dry needling)
• Treating wounds below the dermis by cleansing, soaking, irrigating, soaking, probing, debriding, packing or dressing
• Inserting a hand, finger, or instrument beyond the labia majora or anal verge for the purposes of assessing or rehabilitating pelvic musculature relating to incontinence or pain
• Administering a substance by inhalation (when the substance has been ordered by an authorized person)

Physiotherapists do not have to roster for communicating a diagnosis identifying a disease, physical disorder, or dysfunction as the cause of a person’s symptoms because this is a fundamental part of PT practice. Learn more about rostering. 

Rostering is the process where physiotherapists add their names to a public list indicating they have the required training, education and experience to safely perform the higher risk activity. Physiotherapists who perform authorized activities must roster for each individual authorized activity they perform. 

The only exception is communicating a diagnosis. This is an authorized activity that does not require rostering as it is considered an essential competency.

PTs must roster for the following activities:

• tracheal suctioning
• spinal manipulation
• acupuncture (including dry needling)
• treating a wound below the dermis
• pelvic internal exams (this includes putting an instrument, hand or finger, beyond the labia majora, or beyond the anal verge)
• administering a substance by inhalation

Read the Controlled Acts and Other Restricted Activities Standard to learn more.

Physiotherapists may delegate 3 of the controlled acts they are authorized to perform: tracheal suctioning, wound care and administering a substance by inhalation.

Physiotherapist may NOT delegate: acupuncture, communicating a diagnosis, spinal manipulation, or internal assessment treatment of pelvic musculature

Before delegating to another person, physiotherapists must document that they have:

• Ensured the person they are delegating to has the knowledge, skills, and judgment to carry out the activity safely, competently, and ethically.
• Explained when the person can and cannot perform the controlled act. If the patient’s condition changes or they are high risk for example, it may not be appropriate to delegate a controlled act in this case.
•  Ensured that the person who is carrying out the activity knows how to manage any adverse outcome that can reasonably be foreseen. They must be familiar with the written plan that has been created by the person delegating the activity. 
• Confirmed that the person knows they must not delegate the act to anyone else.

Delegation is a formal transfer of authority and can take place either through a direct order or a medical directive.

Direct orders are when you get the authority to perform a controlled act from another healthcare provider (usually a physician) for a specific client.

A direct order can be written or verbal (although if received verbally, you should document that it was received). A typical direct order would include for example “Patient X to ambulate with 3L O2 maintain SaO2 94+%.”

A medical directive is an order that can be used for several patients when certain conditions exist. For example, a PT may be asked to order x-rays or routine blood work for total hip arthroplasty patients. Medical directives are always written.

Useful Resource for Multi-Disciplinary Teams
An Interprofessional Guide on the Use of Orders, Directives and Delegation for Regulated Health Professionals

Yes, you can delegate 02 titration to a PTA. Physiotherapists can delegate to anyone who has the knowledge, skills and judgement to safely and competently perform the activity – this includes assistants and anyone other health care professional the PT believes is competent.

The acts that can be delegated are:

• administering O2
• suctioning
• wound care

The acts that cannot be delegated are:

• acupuncture (dry needling) and this includes all parts, even removing needles
• spinal manipulation
• communicating a diagnosis
• internal assessment and treatment of pelvic musculature

Remember, when delegating a controlled act to another person, the physiotherapist must document that they have:

• Made sure the person performing the act has the knowledge, skills, and judgement to do so safely, competently and ethically.
• Explained the circumstances in which the person can perform the controlled act, as well as the types of patient with the certain conditions and any other limitations.
• Ensured the assistant knows how to deal with possible adverse outcomes and has a written plan.
• Confirmed that the person they are delegating understands that they cannot delegate this act to anyone else.

Please consider using the Physiotherapist Assistant Competency Checklist when assessing competency and considering delegating any activity.

Yes, delegation is required in this scenario. The controlled act given to physiotherapists is “administering a substance by inhalation” and requires that there be an order for the substance. Even though the PTA is not adjusting the amount of oxygen delivered, if the PTA is changing the delivery of oxygen from the wall to a portable tank, they will need to set up the portable O2 system, which is the same as administering O2 and delegation is required. 

Yes, delegation is required in this scenario. The controlled act given to physiotherapists is “administering a substance by inhalation” and is not limited to adjusting O2 levels. Oxygen is a prescription. 

If the PTA is changing the delivery of oxygen from the wall to a portable tank, they will need to set up the portable O2 system which is administering O2 and delegation is required.

This activity involves risk. The PTA needs special knowledge to do the activity.

For example, the PTA will need to make sure the tank is turned on and has enough oxygen in it. They will need to be certain that they reconnect the hose to the oxygen and not to the air valve. The PTA should know whether to monitor SpO2  during the activity, meaning they may need to increase the flow rate if the patient desaturates. This activity could be a risk to patients and therefore requires delegation. If the patient requires a face mask for their O2 needs, the PTA will need for example to understand the impact on FiO2 and any humidification requirements.

Yes, any time you want to adjust a patient’s 02 level you need to either be rostered or have the authority (to administer, titrate or adjust) delegated to you by an MD (Dentist, Nurse Practitioner, midwife). An order for 02 and the parameters for administration is also always needed.

Same thing with switching between the wall and portable 02 – you may not be adjusting the levels, but you are changing the system where O2 is delivered. The competencies are needed to set up and adjust 02 levels are the same.

If you are not administering or adjusting or titrating or doing anything with a patient’s 02, then you do not need to be rostered.

The function of the pelvic floor is what you, as a physiotherapist, are addressing during the session. Bowel and bladder functions can be closely related to the integrity of the musculoskeletal condition of the pelvic floor.

If you are doing your due diligence during an assessment and asking questions about the frequency of bowel and bladder elimination to assess the pelvic floor, then it does seem reasonable.

If you have highlighted a problem and suggest fibre intake to improve the patient’s bowel motility, you should assess the risk of the recommendation. The risk is there could be another medical condition that you do not have the competency as a PT to evaluate thoroughly.

A physiotherapist cannot diagnose a patient nutritional issue. Of the scenarios in question, the most problematic one is the prescription of the specific elimination diet. It is essential that results from a prescriptive diet are not interpreted by a PT as a nutritional diagnosis.

A physiotherapist should work with an MD or an RD to help guide a patient’s care who is living with chronic diarrhea, as this is not a physiotherapy diagnosis. Collaborative Care Standard

Physiotherapists must be able to prove that they have successfully completed training for the controlled acts they perform. This can be formal education or training delivered on the job. During the training, the physiotherapist must:

• Learn the indications, contraindications, adverse outcomes, and risks associated with performing the controlled act.
• Practice the controlled act under the supervision of a person who is authorized to perform it. 
• Be evaluated on the knowledge, judgement, and practical skills needed to perform the controlled act.
• Show that they are able to safely and competently perform the controlled act.

You can find the full list of requirements that need to be in place before performing a controlled act in the Controlled Acts and Restricted Activities Standard. 

In Ontario, physiotherapists are legally authorized to perform a number of activities referred to in the Regulated Health Professions Act, 1991 (“RHPA”) as controlled acts (or authorized activities). These are activities that are seen to involve a higher level of risk than other activities, so only certain regulated healthcare professionals can perform them.

Physiotherapists are entitled to perform the controlled act / authorized activity of tracheal suctioning if they are on the College’s roster allowing them to perform this activity (which means they have received specific training with respect to this procedure), or they can perform tracheal suctioning if it has been delegated to them by another regulated professional (such as a physician) who has the legal authority to perform tracheal suctioning. Physiotherapists should not accept delegation of any controlled act that they do not believe they are competent to perform. Physiotherapists are encouraged to review the Controlled Acts and Other Restricted Activities Standard before undertaking this work.

The actual controlled act involved in performing tracheal suctioning involves putting an instrument, hand or finger

• beyond the point in the nasal passages where they normally narrow,
• beyond the larynx, or
• into an artificial opening into the body

With the current health human resource shortages, physiotherapists may be asked to assist with patient care in ways they have not experienced before.

Physiotherapists may require additional training to enhance their skills so that they can provide safe, competent care.