California Physical Therapy Ethics, Laws, and Regulations

Course Description: “California Physical Therapy Ethics, Laws, and Regulations” was designed to help therapy professionals with the ethical dilemmas they face in the workplace. The course is designed to promote a better understanding of ethics, morals and legal behavior in the hopes of facilitating a better decision making process for professionals in ethical situations. The information also includes the APTA Code of Ethics, the Standards of Ethical Conduct for the Physical Therapist Assistant, the APTA Guide for Professional Conduct, the APTA Guide for Conduct of the Physical Therapist Assistant and sections of the California Physical Therapy Practice Act pertaining to laws and regulations.

Course Author: Mary Smith, RPT

Methods of Instruction: Online course available via internet

Target Audience: Physical Therapists and Physical Therapist Assistants

Educational Level: Intermediate

Prerequisites: None

Course Goals and Objectives: At the completion of this course, participants should be able to:

1. Define Ethics2. Define Morality3. Identify the basic similarities and differences between ethics and morals4. Differentiate between common ethical theories5. Define determinants of moral and ethical behavior6. Understand the ethical decision-making process7. Interpret and apply the APTA’s Code of Ethics8. Interpret and apply the APTA’s Standards of Ethical Conduct for the

Physical Therapist Assistant9. Understand and incorporate the APTA’s Guide for Professional Conduct for

the Physical Therapist and the Physical Therapist Assistant

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10. Familiarize Physical Therapists and Physical Therapist Assistants with pertinent sections of the California Physical Therapy Practice Act

Criteria for Obtaining Continuing Education Credits: A score of 70% or greater on the post-test

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DIRECTIONS FOR COMPLETING THE COURSE:

1. Review the goals and objectives for the course. 2. Review the course material. 3. We strongly suggest printing out a hard copy of the test. Mark your

answers as you go along and then transfer them to the actual test. A printable test can be found when clicking on “View/Take Test” in your “My Account”.

4. After reading the course material, when you are ready to take the test, go back to your “My Account” and click on “View/Take Test”.

5. A grade of 70% or higher on the test is considered passing. If you have not scored 70% or higher, this indicates that the material was not fully comprehended. To obtain your completion certificate, please re-read the material and take the test again.

6. After passing the test, you will be required to fill out a short survey. After the survey, your certificate of completion will immediately appear. We suggest that you save a copy of your certificate to your computer and print a hard copy for your records.

7. You have up to one year to complete this course from the date of purchase.

8. If we can help in any way, please don’t hesitate to contact us utilizing our live chat, via email at info@advantageceus.com or by phone at 405-974-0164.

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California Physical Therapy Ethics, Laws, and Regulations

Physical therapy should be black and white…right? You go to school, learn how to be a great therapist, graduate with the degree and then rush out to help the world. And usually, it works out that way and

both patients and therapists win. But more and more these days, well intentioned physical therapists are running into situations where the lines between right and wrong blur….where situations aren’t always

black and white….where ethics plays a vital role….

As physical therapists become more autonomous in their role as healthcare providers, ethical situations are more likely to arise. This course is designed to educate therapists about ethics, to help them

make good ethical decisions and feel confident about those decisions.

What “IS” Ethics??

To understand better the concepts of physical therapy ethics, it is good first to have an overview of the discipline of ethics. The word “ethics” is coined from the Greek word ethos which means “character” and from the Latin word mores which means “customs”. Together, they combine and define how individuals make a choice of interacting with one another. In the field of physical therapy, the study of ethics is categorized into normative or philosophical ethics and social scientific or descriptive ethics. Philosophical ethics mainly deals with what people are supposed to do and how they should carry themselves as well as the rationality in making such decisions. Social scientific ethics on the other hand focuses on the study of human ethical behavior with empirical or social scientific tools aiming at exploring the bases of human objectives and the bases of “right” and “wrong” human deeds that enhance or hinder these goals.

The significance of ethics is evidential on several levels. First, when people work in an ethical manner, they feel better about their profession and themselves. Second, ethics builds public trust which increases credibility of professions. Third, ethics promotes business at the organizational level. Businesses that are run ethically perform better than those run in an unethical manner.

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Breaking down the basic definitions…. The Definition of Ethics A set of principles designed to determine right or wrong conduct. A theory or a system of moral values. The study of the general nature of morals and of the specific moral choices to be made by a person; moral philosophy. The rules or standards governing the conduct of a person or the members of a profession. The Definition of Moral Being concerned with principles of right and wrong or conforming to standards of behavior and character based on those principles There are several sub-types of morality. Types of Morality Personal: values and duties you adopt as relevant

In its first, descriptive usage, morality means a code of conduct which is held to be authoritative in matters of right and wrong. Morals are created and defined by society, philosophy, religion, or individual conscience. An example of the descriptive usage could be "common conceptions of morality have changed significantly over time."

Societal: common denominator of shared beliefs

In its second, normative and universal sense, morality refers to an ideal code of conduct, one which would be espoused in preference to alternatives by all rational people, under specified conditions. In this "prescriptive" sense of morality as opposed to the above described "descriptive" sort of sense, moral value judgments such as "murder is immoral" are made. To deny 'morality' in this sense is a position known as moral skepticism, in which the existence of objective moral "truths" is rejected.

Group: shared by the group you belong to such as work, religious, social and professional groups

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In its third usage, 'morality' is synonymous with ethics.

When confronted with an ethical distress or dilemma that needs a decision, there are really three levels in which an ethical decision needs to be made.

1. An ethical problem is one in which the practitioner is confronted by challenges or threats to his or her moral duties and values.

2. Ethical distress occurs when practitioners know the course of action they should take, but for whatever reason, they do not take it. They may be blocked from being the kind of person that they want to be and cannot do the things that they really want to do or they feel is right. There may be institutional or financial barriers.

3. An ethical dilemma is when there are two morally correct courses of action, but they cannot both be followed at the same time.

Ethics versus Morals

People often confuse the words “ethics” and “morals” sometimes using them interchangeably. Notably though, the two words are not identical. The term morals refer to practices whereas ethics usually refers to the rationale that support or oppose such practices. In short, morals are concerned with actions and ethics with reasoning behind such actions. Ethics is usually at a higher intellectual level, more universal, and more emotionally involved than morals.

From time immemorial, man has tried to come up with philosophical bases for determining what is wrong or right. With this several ethical theories have been proposed. Some of generally accepted ethical theories are utilitarianism, social contract theory, deontological theory, ethical intuitionism, ethical egoism, natural law theory and virtue ethics.

Utilitarianism is the idea that the moral worth of an action is determined only by what it can contribute to overall utility. Its worth is its contribution to happiness as summed among all people. It is a form of consequentialism, meaning that the moral worth of an action is determined by its outcome. Utilitarianism is sometimes described by the phrase "the greatest good for the greatest number of people". It is commonly known as "the greatest happiness principle".

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Social contract describes a group of theories that explains how people maintain social order. This theory states that some individuals give up their rights to authority in order for society to maintain a higher and more organized social order.

Deontological theory states that all acts are either inherently good or bad, no matter what the end result is. Most deontological theorists believe that we have a duty to do what is inherently good, even if the end result or consequence is bad.

Ethical Intuitionism is described as common sense or conscience. It states that an act, or decision is ruled as right or wrong depending upon the natural intuition of the individual.

Ethical Egoism operates under the idea that each individual must make decisions based on what is in their own best interests.

Natural law theory is a philosophical and legal belief that all humans are governed by basic innate laws, or laws of nature, which are separate and distinct from laws which are legislated. It infers that natural law is akin to common sense or intuition.

Virtue ethics may be identified as the one that emphasizes the virtues, or moral character, in contrast to the other theories that emphasizes duties or rules. This theory points to how the decision could be good, charitable or benevolent.

Determinants of Ethical/Moral Behavior

There are basically four components to moral behavior - moral sensitivity, moral judgment, moral motivation and moral character. For a good ethical decision to be made, all four of these components have

to be in place. None is more important than the other. All four of them have to be in place to meet the requirement of an ethical decision. 1. Moral Sensitivity Moral sensitivity is the ability to interpret the situation and project the consequences of your actions. If you do not have moral sensitivity, then you do not act ethically because it does not occur that what you are doing is going to affect anybody else.

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2. Moral Judgment Moral judgment is deciding which action is right or wrong because you are able to assess how the different lines of actions that you could take will affect other people. 3. Moral Motivation Moral motivation prioritizes moral values over motives such as self gratification, making money, revenge, protecting your reputation or protecting your organization. 4. Moral Character This is the ability to have the perseverance, the toughness, the conviction and the courage to take action to correct something that you know is wrong. This is taking on the duty to report even if you are not required to report. It is truly the essence of professional behavior. This is the standard that we need to achieve. We need to help people understand that it is their responsibility to stop actions that might be negative for the people that they treat and for the community that we serve. 5. Moral Failure Moral failure occurs when any of these components do not happen. In order to take moral action, you have to have all four of them. It is a complex interaction.

Now that we understand all of the terminology and basic theories, we come down to a more important question. There are so many theories and rules…HOW do I go about making the right ethical decision in my every day practice???

The Ethical Decision-Making Process:

When making ethical decisions, we need to remember the 6 Ethical principles, as they could and SHOULD direct our decisions.

(1) Autonomy: patients have the right to make some decisions as well as we do.

(2) Beneficence: providing care in the best interest of the patient

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(3) Confidentiality: respecting an individual’s right to privacy

(4) Non malfeasance: “do no harm”

(5) Justice: equity or fair treatment

(6) Veracity: truthfulness

It is also important that an individual be able to answer the following questions.

(1) Test for Right versus Wrong- is it obvious?

(2) Legal test: Is it legal?

(3) “PU” test: Does it smell or feel wrong-a test of common sense/conscience

(4) Front page test: How would it look on the front page of the newspaper? Would that make you change your decision or how you feel about the situation?

(5) Mom/Dad Test: How would your parents feel if they knew what you were doing?

(6) The professional ethics test: What do the Code of Ethics, Standards of Ethical Conduct say? Know your practice act and rules and regulations. Be active in your professional organization. Realize that at times, rules and regulations change! Make sure you stay updated at all times.

So what does our national and state organizations have to say about ethics?? The American Physical Therapy Association (APTA) has very clear guidelines on ethical practice. It is a great tool for clinicians to use when making judgments concerning ethical distresses or dilemmas.

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EFFECTIVE JULY 1, 2010. For more information, go to www.apta.org/ethics. CODE OF ETHICS HOD S06-09-07-12 [Amended HOD S06-00-12-23; HOD 06-91-05-05; HOD 06-87-11-17; HOD 06-81-06-18; HOD 06-78-06-08; HOD 06-78-06-07; HOD 06-77-18-30; HOD 06-77-17-27; Initial HOD 06-73-13-24] [Standard]

AMERICAN PHYSICAL THERAPY ASSOCIATION

CODE OF ETHICS Preamble The Code of Ethics for the Physical Therapist (Code of Ethics) delineates the ethical obligations of all physical therapists as determined by the House of Delegates of the American Physical Therapy Association (APTA). The purposes of this Code of Ethics are to: 1. Define the ethical principles that form the foundation of physical therapist practice in patient/client management, consultation, education, research, and administration. 2. Provide standards of behavior and performance that form the basis of professional accountability to the public. 3. Provide guidance for physical therapists facing ethical challenges, regardless of their professional roles and responsibilities. 4. Educate physical therapists, students, other health care professionals, regulators, and the public regarding the core values, ethical principles, and standards that guide the professional conduct of the physical therapist. 5. Establish the standards by which the American Physical Therapy Association can determine if a physical therapist has engaged in unethical conduct. No code of ethics is exhaustive nor can it address every situation. Physical therapists are encouraged to seek additional advice or consultation in instances where the guidance of the Code of Ethics may not be definitive.

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This Code of Ethics is built upon the five roles of the physical therapist (management of patients/clients, consultation, education, research, and administration), the core values of the profession, and the multiple realms of ethical action (individual, organizational, and societal). Physical therapist practice is guided by a set of seven core values: accountability, altruism, compassion/caring, excellence, integrity, professional duty, and social responsibility. Throughout the document the primary core values that support specific principles are indicated in parentheses. Unless a specific role is indicated in the principle, the duties and obligations being delineated pertain to the five roles of the physical therapist. Fundamental to the Code of Ethics is the special obligation of physical therapists to empower, educate, and enable those with impairments, activity limitations, participation restrictions, and disabilities to facilitate greater independence, health, wellness, and enhanced quality of life. Revised APTA Code of Ethics and Standards of Ethical Conduct for the Physical Therapist Assistant Principles: Principle #1: Physical therapists shall respect the inherent dignity and rights of all individuals. (Core Values: Compassion, Integrity) 1A. Physical therapists shall act in a respectful manner toward each person regardless of age, gender, race, nationality, religion, ethnicity, social or economic status, sexual orientation, health condition, or disability. 1B. Physical therapists shall recognize their personal biases and shall not discriminate against others in physical therapist practice, consultation, education, research, and administration. Principle #2: Physical therapists shall be trustworthy and compassionate in addressing the rights and needs of patients/clients. (Core Values: Altruism, Compassion, Professional Duty) 2A. Physical therapists shall adhere to the core values of the profession and shall act in the best interests of patients/clients over the interests of the physical therapist.

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2B. Physical therapists shall provide physical therapy services with compassionate and caring behaviors that incorporate the individual and cultural differences of patients/clients. 2C. Physical therapists shall provide the information necessary to allow patients or their surrogates to make informed decisions about physical therapy care or participation in clinical research. 2D. Physical therapists shall collaborate with patients/clients to empower them in decisions about their health care. 2E. Physical therapists shall protect confidential patient/client information and may disclose confidential information to appropriate authorities only when allowed or as required by law. Principle #3: Physical therapists shall be accountable for making sound professional judgments. (Core Values: Excellence, Integrity) 3A. Physical therapists shall demonstrate independent and objective professional judgment in the patient’s/client’s best interest in all practice settings. 3B. Physical therapists shall demonstrate professional judgment informed by professional standards, evidence (including current literature and established best practice), practitioner experience, and patient/client values. 3C. Physical therapists shall make judgments within their scope of practice and level of expertise and shall communicate with, collaborate with, or refer to peers or other health care professionals when necessary. 3D. Physical therapists shall not engage in conflicts of interest that interfere with professional judgment. 3E. Physical therapists shall provide appropriate direction of and communication with physical therapist assistants and support personnel.

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Principle #4: Physical therapists shall demonstrate integrity in their relationships with patients/clients, families, colleagues, students, research participants, other health care providers, employers, payers, and the public. (Core Value: Integrity) 4A. Physical therapists shall provide truthful, accurate, and relevant information and shall not make misleading representations. 4B. Physical therapists shall not exploit persons over whom they have supervisory, evaluative or other authority (eg, patients/clients, students, supervisees, research participants, or employees). 4C. Physical therapists shall discourage misconduct by health care professionals and report illegal or unethical acts to the relevant authority, when appropriate. 4D. Physical therapists shall report suspected cases of abuse involving children or vulnerable adults to the appropriate authority, subject to law. 4E. Physical therapists shall not engage in any sexual relationship with any of their patients/clients, supervisees, or students. 4F. Physical therapists shall not harass anyone verbally, physically, emotionally, or sexually. Principle #5: Physical therapists shall fulfill their legal and professional obligations. (Core Values: Professional Duty, Accountability) 5A. Physical therapists shall comply with applicable local, state, and federal laws and regulations. 5B. Physical therapists shall have primary responsibility for supervision of physical therapist assistants and support personnel. 5C. Physical therapists involved in research shall abide by accepted standards governing protection of research participants. 5D. Physical therapists shall encourage colleagues with physical, psychological, or substance related impairments that may adversely impact their professional responsibilities to seek assistance or counsel.

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5E. Physical therapists who have knowledge that a colleague is unable to perform their professional responsibilities with reasonable skill and safety shall report this information to the appropriate authority. 5F. Physical therapists shall provide notice and information about alternatives for obtaining care in the event the physical therapist terminates the provider relationship while the patient/client continues to need physical therapy services. Principle #6: Physical therapists shall enhance their expertise through the lifelong acquisition and refinement of knowledge, skills, abilities, and professional behaviors. (Core Value: Excellence) 6A. Physical therapists shall achieve and maintain professional competence. 6B. Physical therapists shall take responsibility for their professional development based on critical self-assessment and reflection on changes in physical therapist practice, education, health care delivery, and technology. 6C. Physical therapists shall evaluate the strength of evidence and applicability of content presented during professional development activities before integrating the content or techniques into practice. 6D. Physical therapists shall cultivate practice environments that support professional development, lifelong learning, and excellence. Principle #7: Physical therapists shall promote organizational behaviors and business practices that benefit patients/clients and society. (Core Values: Integrity, Accountability) 7A. Physical therapists shall promote practice environments that support autonomous and accountable professional judgments. 7B. Physical therapists shall seek remuneration as is deserved and reasonable for physical therapist services. 7C. Physical therapists shall not accept gifts or other considerations that influence or give an appearance of influencing their professional judgment.

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7D. Physical therapists shall fully disclose any financial interest they have in products or services that they recommend to patients/clients. 7E. Physical therapists shall be aware of charges and shall ensure that documentation and coding for physical therapy services accurately reflect the nature and extent of the services provided. 7F. Physical therapists shall refrain from employment arrangements, or other arrangements, that prevent physical therapists from fulfilling professional obligations to patients/clients. Principle #8: Physical therapists shall participate in efforts to meet the health needs of people locally, nationally, or globally. (Core Values: Social Responsibility) 8A. Physical therapists shall provide pro bono physical therapy services or support organizations that meet the health needs of people who are economically disadvantaged, uninsured, and underinsured. 8B. Physical therapists shall advocate to reduce health disparities and health care inequities, improve access to health care services, and address the health, wellness, and preventive health care needs of people. 8C. Physical therapists shall be responsible stewards of health care resources and shall avoid over-utilization or under-utilization of physical therapy services. 8D. Physical therapists shall educate members of the public about the benefits of physical therapy and the unique role of the physical therapist.

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STANDARDS OF ETHICAL CONDUCT FOR THE PHYSICAL THERAPIST ASSISTANT HOD S06-09-20-18 [Amended HOD S06-00-13-24; HOD 06-91-06-07; Initial HOD 06-82-04-08] [Standard]

Standards of Ethical Conduct for the Physical

Therapist Assistant Preamble The Standards of Ethical Conduct for the Physical Therapist Assistant (Standards of Ethical Conduct) delineate the ethical obligations of all physical therapist assistants as determined by the House of Delegates of the American Physical Therapy Association (APTA). The Standards of Ethical Conduct provide a foundation for conduct to which all physical therapist assistants shall adhere. Fundamental to the Standards of Ethical Conduct is the special obligation of physical therapist assistants to enable patients/clients to achieve greater independence, health and wellness, and enhanced quality of life. No document that delineates ethical standards can address every situation. Physical therapist assistants are encouraged to seek additional advice or consultation in instances where the guidance of the Standards of Ethical Conduct may not be definitive. Standards: Standard #1: Physical therapist assistants shall respect the inherent dignity, and rights, of all individuals. 1A. Physical therapist assistants shall act in a respectful manner toward each person regardless of age, gender, race, nationality, religion, ethnicity, social or economic status, sexual orientation, health condition, or disability. 1B. Physical therapist assistants shall recognize their personal biases and shall not discriminate against others in the provision of physical therapy services.

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Standard #2: Physical therapist assistants shall be trustworthy and compassionate in addressing the rights and needs of patients/clients. 2A. Physical therapist assistants shall act in the best interests of patients/clients over the interests of the physical therapist assistant. 2B. Physical therapist assistants shall provide physical therapy interventions with compassionate and caring behaviors that incorporate the individual and cultural differences of patients/clients. 2C. Physical therapist assistants shall provide patients/clients with information regarding the interventions they provide. 2D. Physical therapist assistants shall protect confidential patient/client information and, in collaboration with the physical therapist, may disclose confidential information to appropriate authorities only when allowed or as required by law. Standard #3: Physical therapist assistants shall make sound decisions in collaboration with the physical therapist and within the boundaries established by laws and regulations. 3A. Physical therapist assistants shall make objective decisions in the patient’s/client’s best interest in all practice settings. 3B. Physical therapist assistants shall be guided by information about best practice regarding physical therapy interventions. 3C. Physical therapist assistants shall make decisions based upon their level of competence and consistent with patient/client values. 3D. Physical therapist assistants shall not engage in conflicts of interest that interfere with making sound decisions. 3E. Physical therapist assistants shall provide physical therapy services under the direction and supervision of a physical therapist and shall communicate with the physical therapist when patient/client status requires modifications to the established plan of care.

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Standard #4: Physical therapist assistants shall demonstrate integrity in their relationships with patients/clients, families, colleagues, students, other health care providers, employers, payers, and the public. 4A. Physical therapist assistants shall provide truthful, accurate, and relevant information and shall not make misleading representations. 4B. Physical therapist assistants shall not exploit persons over whom they have supervisory, evaluative or other authority (eg, patients/clients, students, supervisees, research participants, or employees). 4C. Physical therapist assistants shall discourage misconduct by health care professionals and report illegal or unethical acts to the relevant authority, when appropriate. 4D. Physical therapist assistants shall report suspected cases of abuse involving children or vulnerable adults to the supervising physical therapist and the appropriate authority, subject to law. 4E. Physical therapist assistants shall not engage in any sexual relationship with any of their patients/clients, supervisees, or students. 4F. Physical therapist assistants shall not harass anyone verbally, physically, emotionally, or sexually. Standard #5: Physical therapist assistants shall fulfill their legal and ethical obligations. 5A. Physical therapist assistants shall comply with applicable local, state, and federal laws and regulations. 5B. Physical therapist assistants shall support the supervisory role of the physical therapist to ensure quality care and promote patient/client safety. 5C. Physical therapist assistants involved in research shall abide by accepted standards governing protection of research participants. 5D. Physical therapist assistants shall encourage colleagues with physical, psychological, or substance related impairments that may adversely impact their professional responsibilities to seek assistance or counsel.

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5E. Physical therapist assistants who have knowledge that a colleague is unable to perform their professional responsibilities with reasonable skill and safety shall report this information to the appropriate authority. Standard #6: Physical therapist assistants shall enhance their competence through the lifelong acquisition and refinement of knowledge, skills, and abilities. 6A. Physical therapist assistants shall achieve and maintain clinical competence. 6B. Physical therapist assistants shall engage in lifelong learning consistent with changes in their roles and responsibilities and advances in the practice of physical therapy. 6C. Physical therapist assistants shall support practice environments that support career development and lifelong learning. Standard #7: Physical therapist assistants shall support organizational behaviors and business practices that benefit patients/clients and society. 7A. Physical therapist assistants shall promote work environments that support ethical and accountable decision-making. 7B. Physical therapist assistants shall not accept gifts or other considerations that influence or give an appearance of influencing their decisions. 7C. Physical therapist assistants shall fully disclose any financial interest they have in products or services that they recommend to patients/clients. 7D. Physical therapist assistants shall ensure that documentation for their interventions accurately reflects the nature and extent of the services provided. 7E. Physical therapist assistants shall refrain from employment arrangements, or other arrangements, that prevent physical therapist assistants from fulfilling ethical obligations to patients/clients.

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Standard #8: Physical therapist assistants shall participate in efforts to meet the health needs of people locally, nationally, or globally. 8A. Physical therapist assistants shall support organizations that meet the health needs of people who are economically disadvantaged, uninsured, and underinsured. 8B. Physical therapist assistants shall advocate for people with impairments, activity limitations, participation restrictions, and disabilities in order to promote their participation in community and society. 8C. Physical therapist assistants shall be responsible stewards of health care resources by collaborating with physical therapists in order to avoid over-utilization or under-utilization of physical therapy services. 8D. Physical therapist assistants shall educate members of the public about the benefits of physical therapy.

APTA Guide for Professional Conduct

Purpose

This Guide for Professional Conduct (Guide) is intended to serve physical therapists in interpreting the Code of Ethics for the Physical Therapist (Code) of the American Physical Therapy Association (APTA) in matters of professional conduct. The APTA House of Delegates in June of 2009 adopted a revised Code, which became effective on July 1, 2010. The Guide provides a framework by which physical therapists may determine the propriety of their conduct. It is also intended to guide the professional development of physical therapist students. The Code and the Guide apply to all physical therapists. These guidelines are subject to change as the dynamics of the profession change and as new patterns of health care delivery are developed and accepted by the professional community and the public.

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Interpreting Ethical Principles

The interpretations expressed in this Guide reflect the opinions, decisions, and advice of the Ethics and Judicial Committee (EJC). The interpretations are set forth according to topic. These interpretations are intended to assist a physical therapist in applying general ethical principles to specific situations. They address some but not all topics addressed in the Principles and should not be considered inclusive of all situations that could evolve. This Guide is subject to change, and the Ethics and Judicial Committee will monitor and timely revise the Guide to address additional topics and Principles when necessary and as needed.

Preamble to the Code

The Preamble states as follows: The Code of Ethics for the Physical Therapist (Code of Ethics) delineates the ethical obligations of all physical therapists as determined by the House of Delegates of the American Physical Therapy Association (APTA). The purposes of this Code of Ethics are to: 1. Define the ethical principles that form the foundation of physical therapist practice in patient/client management, consultation, education, research, and administration. 2. Provide standards of behavior and performance that form the basis of professional accountability to the public. 3. Provide guidance for physical therapists facing ethical challenges, regardless of their professional roles and responsibilities. 4. Educate physical therapists, students, other health care professionals, regulators, and the public regarding the core values, ethical principles, and standards that guide the professional conduct of the physical therapist. 5. Establish the standards by which the American Physical Therapy Association can determine if a physical therapist has engaged in unethical conduct. No code of ethics is exhaustive nor can it address every situation. Physical therapists are encouraged to seek additional advice or

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consultation in instances where the guidance of the Code of Ethics may not be definitive. This Code of Ethics is built upon the five roles of the physical therapist (management of patients/clients, consultation, education, research, and administration), the core values of the profession, and the multiple realms of ethical action (individual, organizational, and societal). Physical therapist practice is guided by a set of seven core values: accountability, altruism, compassion/caring, excellence, integrity, professional duty, and social responsibility. Throughout the document the primary core values that support specific principles are indicated in parentheses. Unless a specific role is indicated in the principle, the duties and obligations being delineated pertain to the five roles of the physical therapist. Fundamental to the Code of Ethics is the special obligation of physical therapists to empower, educate, and enable those with impairments, activity limitations, participation restrictions, and disabilities to facilitate greater independence, health, wellness, and enhanced quality of life. Interpretation: Upon the Code of Ethics for the Physical Therapist being amended effective July 1, 2010, all the lettered principles in the Code contain the word “shall” and are mandatory ethical obligations. The language contained in the Code is intended to better explain and further clarify existing ethical obligations. These ethical obligations predate the revised Code. Although various words have changed, many of the obligations are the same. Consequently, the addition of the word “shall” serves to reinforce and clarify existing ethical obligations. A significant reason that the Code was revised was to provide physical therapists with a document that was clear enough such that they can read it standing alone without the need to seek extensive additional interpretation. The Preamble states that “no Code of Ethics is exhaustive nor can it address every situation.” The Preamble also states that physical therapists “are encouraged to seek additional advice or consultation in instances in which the guidance of the Code may not be definitive.” Potential sources for advice and counsel include third parties and the myriad resources available on the APTA Web site. Inherent in a physical therapist’s ethical decision-making process is the examination of his or her unique set of facts relative to the Code.

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Topics Respect

Principle 1A states as follows: 1A. Physical therapists shall act in a respectful manner toward each person regardless of age, gender, race, nationality, religion, ethnicity, social or economic status, sexual orientation, health condition, or disability.

Interpretation: Principle 1A addresses the display of respect toward others. Unfortunately, there is no universal consensus about what respect looks like in every situation. For example, direct eye contact is viewed as respectful and courteous in some cultures and inappropriate in others. It is up to the individual to assess the appropriateness of behavior in various situations. Altruism

Principle 2A states as follows: 2A. Physical therapists shall adhere to the core values of the profession and shall act in the best interests of patients/clients over the interests of the physical therapist.

Interpretation: Principle 2A reminds physical therapists to adhere to the profession’s core values and act in the best interest of patients/clients over the interests of the physical therapist. Often this is done without thought, but sometimes, especially at the end of the day when the physical therapist is fatigued and ready to go home, it is a conscious decision. For example, the physical therapist may need to make a decision between leaving on time and staying at work longer to see a patient who was 15 minutes late for an appointment. Patient Autonomy

Principle 2C states as follows: 2C. Physical therapists shall provide the information necessary to allow patients or their surrogates to make informed decisions about physical therapy care or participation in clinical research.

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Interpretation: The underlying purpose of Principle 2C is to require a physical therapist to respect patient autonomy. In order to do so, a physical therapist shall communicate to the patient/client the findings of his/her examination, evaluation, diagnosis, and prognosis. A physical therapist shall use sound professional judgment in informing the patient/client of any substantial risks of the recommended examination and intervention and shall collaborate with the patient/client to establish the goals of treatment and the plan of care. Ultimately, a physical therapist shall respect the patient’s/client’s right to make decisions regarding the recommended plan of care, including consent, modification, or refusal. Professional Judgment

Principles 3, 3A, and 3B state as follows: 3: Physical therapists shall be accountable for making sound professional judgments. (Core Values: Excellence, Integrity) 3A. Physical therapists shall demonstrate independent and objective professional judgment in the patient’s/client’s best interest in all practice settings. 3B. Physical therapists shall demonstrate professional judgment informed by professional standards, evidence (including current literature and established best practice), practitioner experience, and patient/client values.

Interpretation: Principles 3, 3A, and 3B state that it is the physical therapist’s obligation to exercise sound professional judgment, based upon his/her knowledge, skill, training, and experience. Principle 3B further describes the physical therapist’s judgment as being informed by three elements of evidence-based practice. With regard to the patient/client management role, once a physical therapist accepts an individual for physical therapy services he/she shall be responsible for: the examination, evaluation, and diagnosis of that individual; the prognosis and intervention; reexamination and modification of the plan of care; and the maintenance of adequate records, including progress reports. A physical therapist shall establish the plan of care and shall provide and/or supervise and direct the appropriate interventions. Regardless of practice setting, a physical therapist has primary responsibility for the physical therapy care of a patient and shall make independent judgments regarding that care consistent with accepted professional standards. If the diagnostic process reveals findings that are outside the scope of the physical therapist's knowledge,

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experience, or expertise or that indicate the need for care outside the scope of physical therapy, the physical therapist shall so inform the patient/client and shall refer the patient/client to an appropriate practitioner. A physical therapist shall determine when a patient/client will no longer benefit from physical therapy services. When a physical therapist's judgment is that a patient will receive negligible benefit from physical therapy services, the physical therapist shall not provide or continue to provide such services if the primary reason for doing so is to further the financial self-interest of the physical therapist or his/her employer. A physical therapist shall avoid overutilization of physical therapy services. See Principle 8C. Supervision

Principle 3E states as follows: 3E. Physical therapists shall provide appropriate direction of and communication with physical therapist assistants and support personnel.

Interpretation: Principle 3E describes an additional circumstance in which sound professional judgment is required; namely, through the appropriate direction of and communication with physical therapist assistants and support personnel. Further information on supervision via applicable local, state, and federal laws and regulations (including state practice acts and administrative codes) is available. Information on supervision via APTA policies and resources is also available on the APTA Web site. See Principles 5A and 5B. Integrity in Relationships

Principle 4 states as follows: 4: Physical therapists shall demonstrate integrity in their relationships with patients/clients, families, colleagues, students, research participants, other health care providers, employers, payers, and the public. (Core Value: Integrity)

Interpretation: Principle 4 addresses the need for integrity in relationships. This is not limited to relationships with patients/clients, but includes everyone physical therapists come into contact with professionally. For example, demonstrating integrity could encompass working collaboratively with the health care team and taking responsibility for one’s role as a member of that team.

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Reporting Principle 4C states as follows: 4C. Physical therapists shall discourage misconduct by healthcare professionals and report illegal or unethical acts to the relevant authority, when appropriate.

Interpretation: When considering the application of “when appropriate” under Principle 4C, keep in mind that not all allegedly illegal or unethical acts should be reported immediately to an agency/authority. The determination of when to do so depends upon each situation’s unique set of facts, applicable laws, regulations, and policies. Depending upon those facts, it might be appropriate to communicate with the individuals involved. Consider whether the action has been corrected, and in that case, not reporting may be the most appropriate action. Note, however, that when an agency/authority does examine a potential ethical issue, fact finding will be its first step. The determination of ethicality requires an understanding of all of the relevant facts, but may still be subject to interpretation. The EJC Opinion titled: Topic: Preserving Confidences; Physical Therapist's Reporting Obligation With Respect to Unethical, Incompetent, or Illegal Acts provides further information on the complexities of reporting. Exploitation

Principle 4E states as follows: 4E. Physical therapists shall not engage in any sexual relationship with any of their patient/clients, supervisees or students.

Interpretation: The statement is fairly clear – sexual relationships with their patients/clients, supervisees or students are prohibited. This component of Principle 4 is consistent with Principle 4B, which states: Physical therapists shall not exploit persons over whom they have supervisory, evaluative or other authority (e.g. patients/clients, students, supervisees, research participants, or employees). Next, consider this excerpt from the EJC Opinion titled Topic: Sexual Relationships with Patients/Former Patients: A physical therapist stands in a relationship of trust to each patient and has an ethical obligation to act in the patient's best interest and to avoid any exploitation or abuse of the patient. Thus, if a physical therapist has natural feelings of attraction toward a patient, he/she must sublimate

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those feelings in order to avoid sexual exploitation of the patient. One’s ethical decision making process should focus on whether the patient/client, supervisee or student is being exploited. In this context, questions have been asked about whether one can have a sexual relationship once the patient/client relationship ends. To this question, the EJC has opined as follows: The Committee does not believe it feasible to establish any bright-line rule for when, if ever, initiation of a romantic/sexual relationship with a former patient would be ethically permissible. The Committee imagines that in some cases a romantic/sexual relationship would not offend ... if initiated with a former patient soon after the termination of treatment, while in others such a relationship might never be appropriate. Colleague Impairment

Principle 5D and 5E state as follows: 5D. Physical therapists shall encourage colleagues with physical, psychological, or substance-related impairments that may adversely impact their professional responsibilities to seek assistance or counsel. 5E. Physical therapists who have knowledge that a colleague is unable to perform their professional responsibilities with reasonable skill and safety shall report the information to the appropriate authority.

Interpretation: The central tenet of Principles 5D and 5E is that inaction is not an option for a physical therapist when faced with the circumstances described. Principle 5D states that a physical therapist shall encourage colleagues to seek assistance or counsel while Principle 5E addresses reporting information to the appropriate authority. 5D and 5E both require a factual determination on your part. This may be challenging in the sense that you might not know or it might be difficult for you to determine whether someone in fact has a physical, psychological, or substance-related impairment. In addition, it might be difficult to determine whether such impairment may be adversely affecting his or her professional responsibilities. Moreover, once you do make these determinations, the obligation under 5D centers not on reporting, but on encouraging the colleague to seek assistance. However, the obligation under 5E does focus on reporting. But note that 5E discusses reporting when a colleague is unable to perform, whereas 5D discusses encouraging colleagues to seek assistance when the impairment may adversely affect his or her

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professional responsibilities. So, 5D discusses something that may be affecting performance, whereas 5E addresses a situation in which someone is clearly unable to perform. The 2 situations are distinct. In addition, it is important to note that 5E does not mandate to whom you report; it gives you discretion to determine the appropriate authority. The EJC Opinion titled: Topic: Preserving Confidences; Physical Therapist's Reporting Obligation With Respect to Unethical, Incompetent, or Illegal Acts provides further information on the complexities of reporting. Professional Competence

Principle 6A states as follows: 6A. Physical therapists shall achieve and maintain professional competence.

Interpretation: 6A requires a physical therapist to maintain professional competence within one’s scope of practice throughout one’s career. Maintaining competence is an ongoing process of self-assessment, identification of strengths and weaknesses, acquisition of knowledge and skills based on that assessment, and reflection on and reassessment of performance, knowledge and skills. Numerous factors including practice setting, types of patients/clients, personal interests and the addition of new evidence to practice will influence the depth and breadth of professional competence in a given area of practice. Additional resources on Continuing Competence are available on the APTA Web site. Professional Growth

Principle 6D states as follows: 6D. Physical therapists shall cultivate practice environments that support professional development, life-long learning, and excellence.

Interpretation: 6D elaborates on the physical therapist’s obligations to foster an environment conducive to professional growth, even when not supported by the organization. The essential idea is that this is the physical therapist’s responsibility, whether or not the employer provides support.

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Charges and Coding Principle 7E states as follows: 7E. Physical therapists shall be aware of charges and shall ensure that documentation and coding for physical therapy services accurately reflect the nature and extent of the services provided.

Interpretation: Principle 7E provides that the physical therapist must make sure that the process of documentation and coding accurately captures the charges for services performed. In this context, where charges cannot be determined because of payment methodology, physical therapists may review the House of Delegates policy titled Professional Fees for Physical Therapy Services. Additional resources on documentation and coding include the House of Delegates policy titled Documentation Authority for Physical Therapy Services and the Documentation and Coding and Billing information on the APTA Web site. Pro Bono Services

Principle 8A states as follows: 8A. Physical therapists shall provide pro bono physical therapy services or support organizations that meet the health needs of people who are economically disadvantaged, uninsured, and underinsured.

Interpretation: The key word in Principle 8A is “or”. If a physical therapist is unable to provide pro bono services he or she can fulfill ethical obligations by supporting organizations that meet the health needs of people who are economically disadvantaged, uninsured, and underinsured. In addition, physical therapists may review the House of Delegates guidelines titled Guidelines: Pro Bono Physical Therapy Services. Additional resources on pro bono physical therapy services are available on the APTA Web site. 8A also addresses supporting organizations to meet health needs. In terms of supporting organizations, the principle does not specify the type of support that is required. Physical therapists may express support through volunteerism, financial contributions, advocacy, education, or simply promoting their work in conversations with colleagues.

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APTA Guide for Conduct of the Physical Therapist Assistant

Purpose

This Guide for Conduct of the Physical Therapist Assistant (Guide) is intended to serve physical therapist assistants in interpreting the Standards of Ethical Conduct for the Physical Therapist Assistant (Standards) of the American Physical Therapy Association (APTA). The APTA House of Delegates in June of 2009 adopted the revised Standards, which became effective on July 1, 2010.

The Guide provides a framework by which physical therapist assistants may determine the propriety of their conduct. It is also intended to guide the development of physical therapist assistant students. The Standards and the Guide apply to all physical therapist assistants. These guidelines are subject to change as the dynamics of the profession change and as new patterns of health care delivery are developed and accepted by the professional community and the public.

Interpreting Ethical Standards

The interpretations expressed in this Guide reflect the opinions, decisions, and advice of the Ethics and Judicial Committee (EJC). The interpretations are set forth according to topic. These interpretations are intended to assist a physical therapist assistant in applying general ethical standards to specific situations. They address some but not all topics addressed in the Standards and should not be considered inclusive of all situations that could evolve.

This Guide is subject to change, and the Ethics and Judicial Committee will monitor and timely revise the Guide to address additional topics and Standards when necessary and as needed.

Preamble to the Standards

The Preamble states as follows:

The Standards of Ethical Conduct for the Physical Therapist Assistant (Standards of Ethical Conduct) delineate the ethical obligations of all physical therapist assistants as determined by the House of Delegates of the American Physical Therapy Association (APTA). The Standards of Ethical Conduct provide

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a foundation for conduct to which all physical therapist assistants shall adhere. Fundamental to the Standards of Ethical Conduct is the special obligation of physical therapist assistants to enable patients/clients to achieve greater independence, health and wellness, and enhanced quality of life. No document that delineates ethical standards can address every situation. Physical therapist assistants are encouraged to seek additional advice or consultation in instances where the guidance of the Standards of Ethical Conduct may not be definitive.

Interpretation: Upon the Standards of Ethical Conduct for the Physical Therapist Assistant being amended effective July 1, 2010, all the lettered standards contain the word “shall” and are mandatory ethical obligations. The language contained in the Standards is intended to better explain and further clarify existing ethical obligations. These ethical obligations predate the revised Standards. Although various words have changed, many of the obligations are the same. Consequently, the addition of the word “shall” serves to reinforce and clarify existing ethical obligations. A significant reason that the Standards were revised was to provide physical therapist assistants with a document that was clear enough such that they can read it standing alone without the need to seek extensive additional interpretation.

The Preamble states that “[n]o document that delineates ethical standards can address every situation.” The Preamble also states that physical therapist assistants “are encouraged to seek additional advice or consultation in instances where the guidance of the Standards of Ethical Conduct may not be definitive.” Potential sources for advice or counsel include third parties and the myriad resources available on the APTA Web site. Inherent in a physical therapist assistant’s ethical decision-making process is the examination of his or her unique set of facts relative to the Standards.

Standards

Respect

Standard 1A states as follows:

1A. Physical therapist assistants shall act in a respectful manner toward each person regardless of age, gender, race,

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nationality, religion, ethnicity, social or economic status, sexual orientation, health condition, or disability.

Interpretation: Standard 1A addresses the display of respect toward others. Unfortunately, there is no universal consensus about what respect looks like in every situation. For example, direct eye contact is viewed as respectful and courteous in some cultures and inappropriate in others. It is up to the individual to assess the appropriateness of behavior in various situations. Altruism

Standard 2A states as follows:

2A. Physical therapist assistants shall act in the best interests of patients/clients over the interests of the physical therapist assistant.

Interpretation: Standard 2A addresses acting in the best interest of patients/clients over the interests of the physical therapist assistant. Often this is done without thought, but sometimes, especially at the end of the day when the clinician is fatigued and ready to go home, it is a conscious decision. For example, the physical therapist assistant may need to make a decision between leaving on time and staying at work longer to see a patient who was 15 minutes late for an appointment.

Sound Decisions

Standard 3C states as follows:

3C. Physical therapist assistants shall make decisions based upon their level of competence and consistent with patient/client values.

Interpretation: To fulfill 3C, the physical therapist assistant must be knowledgeable about his or her legal scope of work as well as level of competence. As a physical therapist assistant gains experience and additional knowledge, there may be areas of physical therapy interventions in which he or she displays advanced skills. At the same time, other previously gained knowledge and skill may be lost due to lack of use. To make sound decisions, the physical therapist assistant must be able to self-reflect on his or her current level of competence.

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Supervision

Standard 3E states as follows:

3E. Physical therapist assistants shall provide physical therapy services under the direction and supervision of a physical therapist and shall communicate with the physical therapist when patient/client status requires modifications to the established plan of care.

Interpretation: Standard 3E goes beyond simply stating that the physical therapist assistant operates under the supervision of the physical therapist. Although a physical therapist retains responsibility for the patient/client throughout the episode of care, this standard requires the physical therapist assistant to take action by communicating with the supervising physical therapist when changes in the patient/client status indicate that modifications to the plan of care may be needed. Further information on supervision via APTA policies and resources is available on the APTA Web site.

Integrity in Relationships

Standard 4 states as follows:

4: Physical therapist assistants shall demonstrate integrity in their relationships with patients/clients, families, colleagues, students, other health care providers, employers, payers, and the public.

Interpretation: Standard 4 addresses the need for integrity in relationships. This is not limited to relationships with patients/clients, but includes everyone physical therapist assistants come into contact with in the normal provision of physical therapy services. For example, demonstrating integrity could encompass working collaboratively with the health care team and taking responsibility for one’s role as a member of that team.

Reporting

Standard 4C states as follows:

4C. Physical therapist assistants shall discourage misconduct by health care professionals and report illegal or unethical acts to the relevant authority, when appropriate.

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Interpretation: When considering the application of “when appropriate” under Standard 4C, keep in mind that not all allegedly illegal or unethical acts should be reported immediately to an agency/authority. The determination of when to do so depends upon each situation’s unique set of facts, applicable laws, regulations, and policies.

Depending upon those facts, it might be appropriate to communicate with the individuals involved. Consider whether the action has been corrected, and in that case, not reporting may be the most appropriate action. Note, however, that when an agency/authority does examine a potential ethical issue, fact finding will be its first step. The determination of ethicality requires an understanding of all of the relevant facts, but may still be subject to interpretation.

The EJC Opinion titled: Topic: Preserving Confidences; Physical Therapist's Reporting Obligation With Respect to Unethical, Incompetent, or Illegal Acts provides further information on the complexities of reporting. Exploitation

Standard 4E states as follows:

4E. Physical therapist assistants shall not engage in any sexual relationship with any of their patients/clients, supervisees, or students.

Interpretation: The statement is fairly clear – sexual relationships with their patients/clients, supervisees or students are prohibited. This component of Standard 4 is consistent with Standard 4B, which states:

4B. Physical therapist assistants shall not exploit persons over whom they have supervisory, evaluative or other authority (eg, patients/clients, students, supervisees, research participants, or employees).

Next, consider this excerpt from the EJC Opinion titled Topic: Sexual Relationships With Patients/Former Patients (modified for physical therapist assistants):

A physical therapist [assistant] stands in a relationship of trust to each patient and has an ethical obligation to act in the patient's best interest and to avoid any

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exploitation or abuse of the patient. Thus, if a physical therapist [assistant] has natural feelings of attraction toward a patient, he/she must sublimate those feelings in order to avoid sexual exploitation of the patient.

One’s ethical decision making process should focus on whether the patient/client, supervisee or student is being exploited. In this context, questions have been asked about whether one can have a sexual relationship once the patient/client relationship ends. To this question, the EJC has opined as follows:

The Committee does not believe it feasible to establish any bright-line rule for when, if ever, initiation of a romantic/sexual relationship with a former patient would be ethically permissible.

…..

The Committee imagines that in some cases a romantic/sexual relationship would not offend ... if initiated with a former patient soon after the termination of treatment, while in others such a relationship might never be appropriate.

Colleague Impairment

Standard 5D and 5E state as follows:

5D. Physical therapist assistants shall encourage colleagues with physical, psychological, or substance-related impairments that may adversely impact their professional responsibilities to seek assistance or counsel.

5E. Physical therapist assistants who have knowledge that a colleague is unable to perform their professional responsibilities with reasonable skill and safety shall report this information to the appropriate authority.

Interpretation: The central tenet of Standard 5D and 5E is that inaction is not an option for a physical therapist assistant when faced with the circumstances described. Standard 5D states that a physical therapist assistant shall encourage

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colleagues to seek assistance or counsel while Standard 5E addresses reporting information to the appropriate authority.

5D and 5E both require a factual determination on the physical therapist assistant’s part. This may be challenging in the sense that you might not know or it might be difficult for you to determine whether someone in fact has a physical, psychological, or substance- related impairment. In addition, it might be difficult to determine whether such impairment may be adversely affecting someone’s work responsibilities.

Moreover, once you do make these determinations, the obligation under 5D centers not on reporting, but on encouraging the colleague to seek assistance. However, the obligation under 5E does focus on reporting. But note that 5E discusses reporting when a colleague is unable to perform, whereas 5D discusses encouraging colleagues to seek assistance when the impairment may adversely affect his or her professional responsibilities. So, 5D discusses something that may be affecting performance, whereas 5E addresses a situation in which someone is clearly unable to perform. The 2 situations are distinct. In addition, it is important to note that 5E does not mandate to whom you report; it gives you discretion to determine the appropriate authority.

The EJC Opinion titled Topic: Preserving Confidences; Physical Therapist's Reporting Obligation With Respect to Unethical, Incompetent, or Illegal Acts provides further information on the complexities of reporting.

Clinical Competence

Standard 6A states as follows:

6A. Physical therapist assistants shall achieve and maintain clinical competence.

Interpretation: 6A should cause physical therapist assistants to reflect on their current level of clinical competence, to identify and address gaps in clinical competence, and to commit to the maintenance of clinical competence throughout their career. The supervising physical therapist can be a valuable partner in identifying areas of knowledge and skill that the physical therapist assistant needs for clinical competence and to meet the needs of the individual physical therapist, which may vary according to areas of interest and expertise. Further, the physical therapist assistant may request that

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the physical therapist serve as a mentor to assist him or her in acquiring the needed knowledge and skills. Additional resources on Continuing Competence are available on the APTA Web site.

Lifelong Learning

Standard 6C states as follows:

6C. Physical therapist assistants shall support practice environments that support career development and lifelong learning.

Interpretation: 6C points out the physical therapist assistant’s obligation to support an environment conducive to career development and learning. The essential idea here is that the physical therapist assistant encourage and contribute to the career development and lifelong learning of himself or herself and others, whether or not the employer provides support.

Organizational and Business Practices

Standard 7 states as follows:

7. Physical therapist assistants shall support organizational behaviors and business practices that benefit patients/clients and society.

Interpretation: Standard 7 reflects a shift in the Standards. One criticism of the former version was that it addressed primarily face-to-face clinical practice settings. Accordingly, Standard 7 addresses ethical obligations in organizational and business practices on a patient/client and societal level.

Documenting Interventions

Standard 7D states as follows:

7D. Physical therapist assistants shall ensure that documentation for their interventions accurately reflects the nature and extent of the services provided.

Interpretation: 7D addresses the need for physical therapist assistants to make sure that they thoroughly and accurately document the interventions they provide to patients/clients and document related data collected from the patient/client. The focus of

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this Standard is on ensuring documentation of the services rendered, including the nature and extent of such services.

Support - Health Needs

Standard 8A states as follows:

8A. Physical therapist assistants shall support organizations that meet the health needs of people who are economically disadvantaged, uninsured, and underinsured.

Interpretation: 8A addresses the issue of support for those least likely to be able to afford physical therapy services. The Standard does not specify the type of support that is required. Physical therapist assistants may express support through volunteerism, financial contributions, advocacy, education, or simply promoting their work in conversations with colleagues. When providing such services, including pro bono services, physical therapist assistants must comply with applicable laws, and as such work under the direction and supervision of a physical therapist. Additional resources on pro bono physical therapy services are available on the APTA Web site.

California Physical Therapy Laws and Regulations

Laws are created by statutes that originate from legislative bills originally introduced by either the Senate or the Assembly. For example, in 1953 the Physical Therapy Practice Act (Act) was created by Chapter 1823 because of AB 1001. The Physical Therapy Practice Act begins with §2600 in the Business and Professions Code (B&P Code) and governs the practice of physical therapy. The Act, statutes, laws and B&P Code could be considered synonymous. Regulations are standards adopted as rules by the Physical Therapy Board of California to implement, interpret, or make specific the law enforced or administered by the Physical Therapy Practice Act. Regulations must be approved by the Office of Administrative Law, and filed with the Secretary of State Below is an abridged version of the current California Physical Therapy Practice Act. To view this information in its entirety, please go to: http://ptbc.ca.gov/

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2600. This chapter may be cited as the Physical Therapy Practice Act. 2601. For the purpose of this chapter, the following terms shall have the following meanings, unless otherwise specified: (a) "Board" means the Physical Therapy Board of California. (b) "Physical therapist" means a person who is licensed pursuant to this chapter to practice physical therapy. (c) "Physical therapist assistant" means a person who is licensed pursuant to this chapter to assist in the provision of physical therapy under the supervision of a licensed physical therapist. "Physical therapy assistant" and "physical therapist assistant" shall be deemed identical and interchangeable terms. (d) "Physical therapist technician" and "physical therapy aide," as described in Section 2630.4, shall be deemed identical and interchangeable terms. (e) "Physiotherapy" shall be synonymous with "physical therapy." 2602.1. Protection of the public shall be the highest priority for the Physical Therapy Board of California in exercising its licensing, regulatory, and disciplinary functions. Whenever the protection of the public is inconsistent with other interests sought to be promoted, the protection of the public shall be paramount. 2603. The members of the board shall consist of four physical therapists, only one of whom shall be involved in physical therapy education, and three public members. 2604. The members of the board shall be appointed for a term of four years, expiring on the first day of June of each year. The Governor shall appoint one of the public members and the four physical therapist members of the board. No person may serve as a member of the board for more than two consecutive terms. 2611. The board shall meet at least three times each calendar year, meeting at least once each calendar year in northern California and once each calendar year in southern California. The board may convene from time to time until its business is concluded. Special meetings of the board may be held at any time and place as the board may designate. Four members of the board shall constitute a quorum for the transaction of business. 2620.7. (a) Patient records shall be documented as required in regulations promulgated by the board.

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(b) Patient records shall be maintained for a period of no less than seven years following the discharge of the patient, except that the records of unemancipated minors shall be maintained at least one year after the minor has reached 18 years of age, and not in any case less than seven years. 2622. (a) A physical therapist shall be responsible for managing all aspects of the care of each patient as set forth in regulations promulgated by the board. (b) A physical therapist shall not supervise more than two physical therapist assistants at one time to assist the physical therapist in his or her practice of physical therapy. (c) A physical therapist may utilize the services of one aide engaged in patient-related tasks to aid the physical therapist in his or her practice of physical therapy. 2630.3. (a) A licensed physical therapist assistant holding a valid, unexpired, and unrevoked physical therapist assistant license may assist in the provision of physical therapy services only under the supervision of a physical therapist licensed by the board. A licensed physical therapist shall at all times be responsible for the extent, kind, quality, and documentation of all physical therapy services provided by the physical therapist assistant. (b) It is unlawful for any person or persons to hold himself or herself out as a physical therapist assistant, unless at the time of so doing the person holds a valid, unexpired, and unrevoked physical therapist assistant license issued under this chapter, except as authorized in subdivisions (f) and (g) of Section 2630.5. (c) Physical therapist assistants shall not be independently supervised by a physical therapist license applicant or a physical therapist student. (d) A physical therapist assistant shall not perform any evaluation of a patient or prepare a discharge summary. The supervising physical therapist shall determine which elements of the treatment plan, if any, shall be assigned to the physical therapist assistant. Assignment of patient care shall be commensurate with the competence of the physical therapist assistant. 2630.4. (a) A “physical therapy aide” is an unlicensed person, at least 18 years of age, who aids a licensed physical therapist consistent with subdivision (b). (b) The aide shall at all times be under the supervision of the physical therapist. An aide shall not independently perform physical therapy or any physical therapy procedure. The board shall adopt regulations that

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set forth the standards and requirements for the supervision of an aide by a physical therapist. (c) Physical therapy aides shall not be independently supervised by a physical therapist license applicant, or a physical therapist student. (d) This section does not prohibit the administration by a physical therapy aide of massage, external baths, or normal exercise not a part of a physical therapy treatment. 2633.5. (a) Only a person licensed as a physical therapist assistant by the board may use the title “physical therapist assistant” or “physical therapy assistant” or the letters “PTA” or any other words, letters, or figures that indicate that the person is a physical therapist assistant licensed pursuant to this chapter. (b) The license of a physical therapist assistant shall not authorize the use of the prefix “LPT,” “RPT,” “PT,” or “Dr.,” or the title “physical therapist,” “therapist,” “doctor,” or any affix indicating or implying that the physical therapist assistant is a physical therapist or doctor. 2633.7. During a period of clinical practice or in any similar period of observation of related educational experience involving recipients of physical therapy, a person so engaged shall be identified only as a “physical therapist student” or a “physical therapist assistant student,”. 2644. (a) Every license issued under this chapter shall expire at 12 a.m. on the last day of the birth month of the licensee during the second year of a two-year term, if not renewed. (b) The licensee shall disclose on his or her license renewal application any misdemeanor or other criminal offense for which he or she has been found guilty or to which he or she has pleaded guilty or no contest. 2646. A license that has expired may be renewed at any time within five years after its expiration by applying for renewal as set forth in Section 2644. Renewal under this section shall be effective on the date on which the renewal application is filed, on the date on which the renewal fee or accrued renewal fees are paid, or on the date on which the delinquency fee and penalty fee, if any, are paid, whichever last occurs. A renewed license shall continue in effect through the expiration date set forth in Section 2644 that next occurs after the effective date of the renewal, at which time it shall expire and become invalid if it is not so renewed. 2647. A person who fails to renew his or her license within five years after its expiration may not renew it, and it shall not be reissued,

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reinstated, or restored thereafter. However, the person may apply for a new license if he or she satisfies the requirements set forth in Article 3 (commencing with Section 2635). 2650. (a) The physical therapist education requirements are as follows: (1) Except as otherwise provided in this chapter, each applicant for a license as a physical therapist shall be a graduate of a professional degree program of an accredited postsecondary institution or institutions approved by the board and shall have completed a professional education program including academic course work and clinical internship in physical therapy. (2) Unless otherwise specified by the board by regulation, the educational requirements shall include instruction in the subjects prescribed by the Commission on Accreditation in Physical Therapy Education (CAPTE) of the American Physical Therapy Association or Physiotherapy Education Accreditation Canada and shall include a combination of didactic and clinical experiences. The clinical experience shall include at least 18 weeks of full-time experience with a variety of patients. (b) The physical therapist assistant educational requirements are as follows: (1) Except as otherwise provided in this chapter, each applicant for a license as a physical therapist assistant shall be a graduate of a physical therapist assistant program of an accredited postsecondary institution or institutions approved by the board, and shall have completed both the academic and clinical experience required by the physical therapist assistant program, and have been awarded an associate degree. (2) Unless otherwise specified by the board by regulation, the educational requirements shall include instruction in the subjects prescribed by the CAPTE of the American Physical Therapy Association or Physiotherapy Education Accreditation Canada or another body as may be approved by the board by regulation and shall include a combination of didactic and clinical experiences. 2651. The board shall approve only those physical therapist and physical therapist assistant education programs that prove to the satisfaction of the board that they comply with the minimum physical therapist or physical therapist assistant educational requirements set forth in this chapter and adopted by the board pursuant to this chapter. Physical therapist and physical therapist assistant education programs that are accredited by the Commission on Accreditation in Physical Therapy Education of the American Physical Therapy Association, Physiotherapy Education Accreditation Canada, or

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such other body as may be approved by the board by regulation shall be deemed approved by the board unless the board determines otherwise. This chapter shall not prohibit the board from disapproving any foreign physical therapist or physical therapist assistant educational program or from denying an applicant if, in the opinion of the board, the instruction received by the applicant or the courses offered by the program were not equivalent to that which is required by this chapter. 2653. An applicant for a license as a physical therapist who has graduated from a physical therapist education program that is not approved by the board and is not located in the United States shall do all of the following: (a) Furnish documentary evidence satisfactory to the board, that he or she has completed a professional degree in a physical therapist educational program substantially equivalent at the time of his or her graduation to that issued by a board approved physical therapist education program. The professional degree must entitle the applicant to practice as a physical therapist in the country where the diploma was issued. The applicant shall meet the educational requirements set forth in paragraph (2) of subdivision (a) of Section 2650. The board may require an applicant to submit documentation of his or her education to a credentials evaluation service for review and a report to the board. (b) Demonstrate proficiency in English by achieving a score specified by the board on the Test of English as a Foreign Language administered by the Educational Testing Services or such other examination as may be specified by the board by regulation. (c) Complete nine months of clinical service in a location approved by the board under the supervision of a physical therapist licensed by a United States jurisdiction, in a manner satisfactory to the board. The applicant shall have passed the written examination required in Section 2636 prior to commencing the period of clinical service. The board shall require the supervising physical therapist to evaluate the applicant and report his or her findings to the board. The board may in its discretion waive all or part of the required clinical service pursuant to guidelines set forth in its regulations. During the period of clinical service, the applicant shall be identified as a physical therapist license applicant. If an applicant fails to complete the required period of clinical service, the board may, for good cause shown, allow the applicant to complete another period of clinical service. 2654. If an applicant who has graduated from a physical therapist education program that is not approved by the board and is not

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located in the United States does not qualify to take the physical therapist examination, his or her education may be evaluated by the board and the applicant may be eligible to take the physical therapist assistant examination.

2660. Unprofessional conduct constitutes grounds for citation, discipline, denial of a license, or issuance of a probationary license. The board may, after the conduct of appropriate proceedings under the Administrative Procedure Act issue a citation, impose discipline, deny a license, suspend for not more than 12 months, or revoke, or impose probationary conditions upon any license issued under this chapter for unprofessional conduct that includes, in addition to other provisions of this chapter, but is not limited to, the following: (a) Violating or attempting to violate, directly or indirectly, assisting in or abetting the violation of, or conspiring to violate any provision of this chapter, any regulations duly adopted under this chapter, or the Medical Practice Act (Chapter 5 (commencing with Section 2000)). (b) Advertising in violation of Section 17500. (c) Obtaining or attempting to obtain a license by fraud or misrepresentation. (d) Practicing or offering to practice beyond the scope of practice of physical therapy. (e) Conviction of a crime that substantially relates to the qualifications, functions, or duties of a physical therapist or physical therapist assistant. The record of conviction or a certified copy thereof shall be conclusive evidence of that conviction. (f) Unlawful possession or use of, or conviction of a criminal offense involving, a controlled substance as defined in Division 10 (commencing with Section 11000) of the Health and Safety Code, or any dangerous drug as defined in Article 2 (commencing with Section 4015) of Chapter 9, as follows: (1) Obtaining or possessing in violation of law, or except as directed by a licensed physician and surgeon, dentist, or podiatrist, administering to himself or herself, or furnishing or administering to another, any controlled substances or any dangerous drug. (2) Using any controlled substance or any dangerous drug. (3) Conviction of a criminal offense involving the consumption or self-administration of, or the possession of, or falsification of a record pertaining to, any controlled substance or any dangerous drug, in which event the record of the conviction is conclusive evidence thereof. (g) Failure to maintain adequate and accurate records relating to the provision of services to his or her patients. (h) Gross negligence or repeated acts of negligence in practice or in the delivery of physical therapy care.

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(i) Aiding or abetting any person to engage in the unlawful practice of physical therapy. (j) The commission of any fraudulent, dishonest, or corrupt act that is substantially related to the qualifications, functions, or duties of a physical therapist or physical therapist assistant. (k) Except for good cause, the knowing failure to protect patients by failing to follow infection control guidelines of the board, thereby risking transmission of bloodborne infectious diseases from licensee to patient, from patient to patient, and from patient to licensee. In administering this subdivision, the board shall consider referencing the standards, regulations, and guidelines of the State Department of Public Health developed pursuant to Section 1250.11 of the Health and Safety Code and the standards, regulations, and guidelines pursuant to the California Occupational Safety and Health Act of 1973 (Part 1 (commencing with Section 6300) of Division 5 of the Labor Code) for preventing the transmission of HIV, hepatitis B, and other bloodborne pathogens in health care settings. As necessary, the board shall consult with the Medical Board of California, the California Board of Podiatric Medicine, the Dental Board of California, the Board of Registered Nursing, and the Board of Vocational Nursing and Psychiatric Technicians of the State of California, to encourage appropriate consistency in the implementation of this subdivision. (l) The commission of verbal abuse or sexual harassment. (m) Engaging in sexual misconduct or violating Section 726. (n) Permitting a physical therapist assistant or physical therapy aide under one’s supervision or control to perform, or permitting the physical therapist assistant or physical therapy aide to hold himself or herself out as competent to perform, professional services beyond the level of education, training, and experience of the physical therapist assistant or aide. (o) The revocation, suspension, or other discipline, restriction, or limitation imposed by another state upon a license or certificate to practice physical therapy issued by that state, or the revocation, suspension, or restriction of the authority to practice physical therapy by any agency of the federal government. (p) Viewing a completely or partially disrobed patient in the course of treatment if the viewing is not necessary to patient evaluation or treatment under current standards. (q) Engaging in any act in violation of Section 650, 651, or 654.2. (r) Charging a fee for services not performed. (s) Misrepresenting documentation of patient care or deliberate falsifying of patient records. (t) Except as otherwise allowed by law, the employment of runners, cappers, steerers, or other persons to procure patients. (u) The willful, unauthorized violation of professional confidence.

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(v) Failing to maintain confidentiality, except as otherwise required or permitted by law, of all information that has been received from a patient in confidence during the course of treatment and all information about the patient that is obtained from tests or other means. (w) Habitual intemperance. (x) Failure to comply with the provisions of Section 2620.1. 2660.1. A patient, client, or customer of a licentiate under this chapter is conclusively presumed to be incapable of giving free, full, and informed consent to any sexual activity which is a violation of Section 726. 2660.2. (a) The board may refuse a license to any applicant guilty of unprofessional conduct or sexual activity referred to in Section 2660.1

CALIFORNIA CODE OF REGULATIONS TITLE 16, DIVISION 13.2

Article 4. Physical Therapist Assistants 1398.44. Adequate Supervision Defined (a) "Adequate supervision" of a physical therapist assistant shall mean supervision that complies with this section. A physical therapist shall at all times be responsible for all physical therapy services provided by the physical therapist assistant and shall ensure that the physical therapist assistant does not function autonomously. The physical therapist has a continuing responsibility to follow the progress of each patient, and is responsible for determining which elements of a treatment plan may be assigned to a physical therapist assistant. (b) A physical therapist who performs the initial evaluation of a patient shall be the physical therapist of record for that patient. The physical therapist of record shall remain as such until a reassignment of that patient to another physical therapist of record has occurred. The physical therapist of record shall ensure that a written system of transfer to the succeeding physical therapist exists. (c) The physical therapist of record shall provide supervision and direction to the physical therapist assistant in the treatment of patients to whom the physical therapist assistant is providing care. The physical therapist assistant shall be able to identify, and communicate with, the physical therapist of record at all times during the treatment of a patient. (d) A physical therapist assistant shall not:

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(1) Perform measurement, data collection or care prior to the evaluation of the patient by the physical therapist (2) Document patient evaluation and reevaluation (3) Write a discharge summary (4) Establish or change a plan of care (5) Write progress reports to another health care professional, as distinguished from daily chart notes (6) Be the sole physical therapy representative in any meeting with other health care professionals where the patient's plan of care is assessed or may be modified. (7) Supervise a physical therapy aide performing patient-related tasks (8) Provide treatment if the physical therapist assistant holds a management position in the physical therapy business where the care is being provided. For purposes of this section, "management position" shall mean a position that has control or influence over scheduling, hiring, or firing. The prohibitions in subsection (d) above shall not prohibit a physical therapist assistant from collecting and documenting data, administering standard tests, or taking measurements related to patient status. (e) The physical therapist assistant shall: (1) Notify the physical therapist of record, document in the patient record any change in the patient's condition not within the planned progress or treatment goals, and any change in the patient's general condition. Article 6. Physical Therapy Aides 1399. Requirements for Use of Aides (a) A physical therapy aide is an unlicensed person who may be utilized by a physical therapist in his or her practice by performing non-patient related tasks, or by performing patient related tasks. (b) Prior to the aide providing patient related care, a physical therapist shall evaluate and document, the aide's competency level for performing the patient related task that the aide will provide in that setting. The record of competencies shall be made available to the board or any physical therapist utilizing that aide upon request. (c) As used in these regulations: (1) A "patient related task" means a physical therapy service rendered directly to the patient by an aide, excluding non-patient related tasks as defined below. (2) A "non-patient related task" means a task related to observation of the patient, transport of patients, physical support only during gait or transfer, housekeeping duties, clerical duties and similar functions.

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(3) "Under the orders, direction and immediate supervision" means: (A) Prior to the initiation of care, the physical therapist shall evaluate every patient prior to the performance of any patient related tasks by the aide. (B) The physical therapist shall formulate and record in the patient's record a treatment program based upon the evaluation and any other information available to the physical therapist, and shall determine those patient related tasks which may be assigned to an aide. (C) The physical therapist shall assign only those patient related tasks that can be safely and effectively performed by the aide. The physical therapist shall be responsible at all times for the conduct of the aide while the aide is performing "patient related tasks" and "non-patient related tasks" as defined in this section. (D) The physical therapist shall provide continuous and immediate supervision of the aide. The physical therapist shall be in the same facility as the aide and in immediate proximity to the location where the aide is performing patient related tasks. The physical therapist shall be readily available at all times to provide immediate advice, instruction or intervention in the care of the patient. When patient related tasks are provided to a patient by an aide the physical therapist shall at some point during the treatment day provide direct service to the patient as treatment for the patient's condition or to further evaluate and monitor the patient's progress. (E) The physical therapist shall perform periodic re-evaluation of the patient as necessary and make adjustments in the patient's treatment program. The re-evaluation shall be documented in the patient's record. Article 12. Topical Medications 1399.75. Compliance with Regulations A physical therapist may apply or administer topical medications to a patient as set forth in this article. 1399.76. Topical Medications Defined As used in this article "topical medications" means medications applied locally to the skin or underlying tissue where there is a break in or absence of the skin where such medications require a prescription or order under federal or state law. 1399.77. Administration of Medications Topical medications may be administered by a physical therapist by:

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(a) Direct application; (b) Iontophoresis; or (c) Phonophoresis. 1399.78. Authorization and Protocols Required Topical medications shall be applied or administered by a physical therapist in accordance with this section. (a) Any topical medication applied or administered shall be ordered on a specific or standing basis by a practitioner legally authorized to order or prescribe such medication. (b) Written protocols shall be prepared for the administration or application of each of the groups of medications listed in Section 1399.79 for which a prescription is required under Federal or State law, which shall include a description of the medication, its actions, its indications and contraindications, and the proper procedure and technique for the application or administration of medication. 1399.79. Authorized Topical Medications A physical therapist may apply or administer those topical medications listed in this section in accordance with the provisions of this article: (a) Bacteriocidal agents; (b) Debriding agents; (c) Topical anesthetic agents; (d) Anti-inflammatory agents; (e) Antispasmodic agents; and (f) Adrenocortico-steroids.

Case Studies

Case Study # 1 John Brown works for XYZ home health company. Mr. Brown has a patient that he is getting ready to discharge with all goals met. The patient is independent at home and in the community. The patient is also driving and no longer homebound. Mr. Brown contacts the home health agency to discuss his upcoming discharge. The office manager asks how many visits the patient will have received at discharge. John Brown states the patient will be discharged with a total of 13 physical therapy visits. The office manager tells him that he needs to “squeeze in one more visit” so the home health company would receive a larger overall reimbursement from Medicare.

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What is the ethical response? Mr. Brown is torn between helping his employer financially benefit from “squeezing in one more visit” and the fact that the patient is now independent. According to the APTA’s Code of Ethics, Principle 7B states that “A physical therapist shall seek only remuneration as is deserved and reasonable for physical therapy services.” At this point, it is not ethical to bill for the additional visit. All the goals have been met and adding an additional visit would only be done to capture the increase in Medicare reimbursement. Also, The APTA Guide for Professional Conduct also states “When a physical therapist's judgment is that a patient will receive negligible benefit from physical therapy services, the physical therapist shall not provide or continue to provide such services if the primary reason for doing so is to further the financial self-interest of the physical therapist or his/her employer. A physical therapist shall avoid overutilization of physical therapy services.” Case Study # 2 ABC outpatient clinic was approached by Dr. Jones with a proposal. Dr. Jones tells the clinic owners that if they will provide him $1000 in compensation each month, he will refer all of his therapy patients to their clinic. Is this an ethical approach? Dr. Jones is an orthopedic physician and his referrals would greatly increase ABC’s patient load and in turn their profits. Under the APTA’s Code of Ethics, principle 4C states that “Physical therapists shall discourage misconduct by health care professionals and report illegal or unethical acts to the relevant authority, when appropriate.”

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Bibliography Barnitt, R. (1998). Ethical dilemmas in Occupational Therapy and

Physical Therapy: A Survey of Practitioners in the UK National Health Service. Journal of Medical Ethics. 3(24): 193

Boylan, M. (2000). Basic Ethics. Englewood Cliffs, NJ: Prentice-Hall Corey, G., Corey, M.S., & Callahan, P. (1988). Issues and ethics in the

helping professions. Pacific Grove, CA: Brooks and Cole. Gabard, Donald L. (2003). Physical Therapy Ethics. University,

Orange County: F.A. Davis Company. Jensen, G. M., Gwyer, J., Shepard, K.F. & Hack, L.M. (2000). Expert

practice in physical therapy. Physical Therapy. 80:28–43 Kirsch, N., Iglarsh, A. (2006). Ethical Decision Making to Avoid

Disciplinary Action. Federation Forum Magazine. 22:1 Odom, J.G. (1988) The status of ethics instruction in the health care

curriculum. Heath Education, 19(4), 9-12. Rose, S.J. (1989). Editor's note: Our body of knowledge revisited. Physical Therapy. 69:297–298 Venglar, M., Theall, M. (2007). Case-Based Ethics Education in Physical Therapy. The Journal of Scholarship of Teaching and Learning. 7:1 Thiroux, J.P. (1995). Ethics: Theory and Practice. 5th ed. Englewood http://www.apta.org/Ethics/Core/ www.ptbc.ca.gov

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