PHY-POL-002: Assistant scope and supervision

Policy · PHY-POL-002 · Version 1.0 · Approved by the ASF Expert Committee

Supports: 18.2

At a glance

Physiotherapy is delivered by qualified physiotherapists, or by assistants under their supervision.
Each assistant has a written scope of practice, approved by the lead physiotherapist.
Supervision is recorded for each assistant, and an assistant does not treat a patient alone beyond their scope.
The qualification of each physiotherapist is verified before work starts (PHY-REG-001).
Stop and get help straight away if: an assistant treats a patient alone beyond their scope.

1. Purpose

To make sure only qualified staff, or supervised assistants within a written scope, deliver treatment (18.2).

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 is a skilled service. Patients are safe when treatment is given by qualified staff, and when assistants work only within the scope set for them and under supervision.

5. Responsibilities

Role	Responsibility	Competence
Lead physiotherapist	Approves scopes and supervision	Clinician
Assistants	Work within the written scope only	Assistant

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. Write the scope.

Write each assistant’s scope of practice and have it approved.

Key point: Scope approved.

Step 2. Supervise.

Record the supervision for each assistant.

Key point: Supervised and recorded.

Step 3. Check qualifications.

Verify each physiotherapist’s qualification on PHY-REG-001 before work starts.

Key point: Verified.

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
Assistant treatments within the written scope	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-REG-001	Qualification and scope register	Register
STF-SOP-001	Staff credential verification and recheck (existing, reused)	Procedure

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: Assistant scope and supervision in physiotherapy. 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)

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