Standards › Standard 18 › Policies
Policy · PHY-POL-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 18.1
At a glance
- A physiotherapist assesses each patient before treatment starts.
- The assessment records the problem, the goals, any contraindications and any red flags (PHY-FRM-001).
- A red flag is referred to a doctor the same day, and the referral is recorded.
- The treatment goals are agreed with the patient and written down before treatment.
- Stop and get help straight away if: treatment starts with no assessment on file.
1. Purpose
To make sure every patient is assessed, and that red flags are found and referred, before treatment begins (18.1).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
Physiotherapy starts with a clear picture of the patient’s problem, function and goals. Without an assessment before treatment, the treatment is guesswork and cannot be measured later.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Lead physiotherapist | Owns the assessment standard | Clinician |
| Treating physiotherapist | Assesses, agrees goals and refers red flags | Clinician |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Assess.
- Assess the patient and record the problem, contraindications and red flags on PHY-FRM-001.
Key point: Assessed.
Step 2. Refer red flags.
- Refer any red flag to a doctor the same day, and record the referral.
Key point: Referred.
Step 3. Agree goals.
- Agree the goals with the patient and record them before treatment.
Key point: Agreed and recorded.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Patients with an assessment on file before treatment | 100% | Monthly | Lead physiotherapist | Escalate to medical director |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| PHY-FRM-001 | Physiotherapy assessment record | Record |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WCPT Descriptor of physical therapy (2019) and the WHO Rehabilitation in health systems guide (2019). |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
E-learning for this document
No e-learning course is linked to this document yet.
Planned course: Physiotherapy assessment before treatment. New course planned.
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)