CASLPO = College of Audiologists and Speech-Language Pathologists
CPO = College of Physiotherapists of Ontario
CCAC = Community Care Access Centre
CCO = College of Chiropractors of Ontario
CMTO = College of Massage Therapists of Ontario
CKO = College of Kinesiologists of Ontario
COTO = College of Occupational Therapists of Ontario
FHRCO = Federation of Health Regulatory Colleges of Ontario

Component What’s the same? What’s different?
Consent All Colleges require that all written and verbal (oral) consents be documented. The exact amount of information depends on the circumstances, risk and type of consent. All members must follow the requirements of College standards, the Health Care Consent Act, 1996 and the Personal Health Information Protection Act, 2004. There are no significant differences
Initial Intake, Information Gathering & Assessment All Colleges require documentation of all subjective and objective data and information gathered by the member. This includes information from other sources, consultations and correspondence from other health professionals. COTO requires the retention of raw data used to inform care plans
• Personal Identification All Colleges require that demographic information be collected, for example, name and date of birth. The goal is to uniquely identify the client. Colleges may list specific elements of demographic information that should be requested. Clients have the option to decline to provide.
• Appointment Information Required by all Colleges Different terms of appointment information may be used, for example “visit” or “contact” or “professional encounter.”
• Referral Sources Record where available and appropriate There are no significant differences
• Health History Required by all. All professionals are expected to use their judgement as to the level of detail needed. CMTO and CCO both give specifics around what information should be contained in the health history.
• Initial Assessments/Examinations and Objective Tests Required by all CMTO and CCO both give specifics around what information should be contained in initial assessments/examinations.
• Information From Other Sources Required by all, such as “reports”, “test results”NOTE: there is no need to duplicate information already collected and documented by another provider There are no significant differences
Analysis/Diagnosis/Clinical Impressions All Colleges require the documentation of the information gathered as well as an analysis, clinical impression or diagnosis There are no significant differences
Care/Treatment/Interventions All Colleges require documentation of the care, treatment or interventions provided. This includes but is not limited to:

  • treatment plans
  • treatments provided, which includes outcomes achieved, both negative and positive, and subsequent actions taken
  • performance of controlled acts and any delegation of authority if permitted (see profession specific standards and FHRCO delegation resources)
  • care assigned to others
  • recommendations, advice, education
  • referrals to other practitioners
  • reports to other care providers or organizations (e.g. family physicians, insurers, CCACs, etc.)
  • records of any missed appointments, cancellations and the reasons why, where applicable
  • records of any treatments that were commenced and not completed or refused outright
Some Colleges do not stipulate that reasons for missed/cancelled appointments and suspended treatments be documented; however, this is recommended practice.Massage therapists and occupational therapists are required to also document appointment duration.
Reassessments/Progress Re-assessments should be done at appropriate intervals (based on clinical judgment and consistent with individual college standards). Any changes (or lack of expected changes) in the patient’s condition should be documented. All re-assessments and changes to the treatment plan should be documented. There are no significant differences.
Discharge/Discontinuance All Colleges expect members to document any discharge plans or reasons for discontinuing care. The level of detail that is required will vary with the circumstances.
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COTO and COKO standards provide specific guidance on discharging clients.

In Practice/In Summary

Recovering from a serious car accident resulting in mobility and communication issues due to a head injury as well as a leg and shoulder fracture, Jenny is referred to Willow Pines clinic for treatment from multiple disciplines—the name of the physician, contact information and reason for the referral are noted in the record.

During her first visit, Jenny answers several questions about her health history, which are captured in her health record. Jenny is pleased that during subsequent visits, she is not asked to repeat the same information but notes that new care providers do confirm the information with her.

Jenny’s appointments with each of the professionals at the clinic result in a comprehensive plan of care, shared with her referring physician. After a follow up visit with the orthopedic surgeon, Jenny is allowed to progress her weight bearing status. The orthopedic surgeon emails a progress report to the clinic, which is included in Jenny’s health record. This results in the PT upgrading her gait aid and the Kinesiologist progressing her strengthening exercises.

With the increased activity, Jenny begins to experience more pain. This impacts the SLP’s communication therapy because of the effects on her attention and concentration. Jenny also misses several appointments as a result. The missed appointments are noted by the OT who recognizes the impact of pain on cognition and gathers the team to discuss Jenny’s on-going treatment plan. A follow up visit with the GP is recommended and after a change of pain meds and the addition of massage therapy Jenny is back on track—all of this is captured in her health record.

After several weeks of care, Jenny’s insurance company asks for a copy of her file. The receptionist is able to download a copy that includes notes from all providers involved and provides an overall picture of the care she has received.

Jenny’s care continues until one by one she achieves her goals and is discharged from care.