Click here to view Standard 4.1 Safety and Risk Management as a PDF document

Standard

A registrant of RCASLPNB practices in compliance with occupational health, safety and risk management regulations and requirements in all practice settings.

Indicators

To demonstrate this standard, the registrant will:

1. Comply with occupational health and safety legislation and agency or employer policies and procedures related to safe work practices.
2. Participate in appropriate training related to occupational health and workplace safety.
3. Identify and manage potential risks that may impact safety in the work environment, such as working alone or environmental hazards.
4. Respond promptly to accidents and emergencies to minimize their impact, while also documenting incidents to support future prevention efforts.
5. Ensure the safe handling and cleanliness of equipment, supplies and potentially infectious substances according to infection prevention and control standards.
6. Use personal protective equipment and supplies as appropriate or mandated (e.g., goggles, gloves).
7. Inspect, calibrate and maintain equipment according to manufacturers' standards and keep a log documenting these practices.
8. Comply with reporting procedures related to incidents involving workplace safety.

Expected Outcome

Patients or clients can expect that all relevant legislation, government mandates, and workplace requirements regarding occupational health, safety, and risk management will be followed.

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Glossary

Patient or client refers to a recipient of the services of an audiologist or speech-language pathologist.

Registrant means an audiologist or a speech-language pathologist and any person whose name is entered in the temporary register or in any of the rosters established and maintained under the Audiology and Speech-Language Pathology Act, the bylaws and rules.

Risk management refers to the identification, assessment, and prioritization of risks followed by coordinated application of resources to minimize, monitor, and control the probability and/or impact of unfortunate events.

Click here to view Standard 4.2 Documentation and Information Management as a PDF document

Standard

A registrant of RCASLPNB maintains clear, confidential, accurate, legible, timely, and complete records, in compliance with all relevant provincial legislation and regulatory requirements. The main goal of documentation is to ensure that anyone reviewing a patient or client record can understand the care provided- including what was done, for whom, by whom, when, why and how it was evaluated.

Indicators

To demonstrate this standard, the registrant will:

1. Maintain and disclose all documentation, correspondence, and records in compliance with applicable legislation and regulatory requirements, including confidentiality and privacy standards.
2. Use language that is free of bias which might imply prejudicial beliefs or perpetuate assumptions regarding the individual(s) being written about.
3. Document events, decisions, outcomes, etc. in chronological order.
4. Inform employers, support personnel (i.e.: communication health assistants), and others of their professional obligations regarding documentation and record keeping.
5. Avoid using social media as a means for communicating directly with patients or clients due to privacy and confidentiality
6. Access and disclose information only as needed and in compliance with relevant provincial legislation.
7. Retain or ensure access to copies of care pathways or protocols in addition to patient or client records in circumstances where patient or client care delivery and documentation is according to a protocol, or where charting by exception is employed.
8. Ensure that any abbreviations and acronyms used are written out in full, with the abbreviation in brackets the first time it is stated in any continuous document entry (i.e., a formal report would constitute one continuous document entry, as would chart notes). Subsequent use of the abbreviation in the continuous document is acceptable.
9. Make every reasonable effort to confirm that all professional correspondence is sent to the intended recipient and report breaches in compliance with relevant provincial legislation and workplace policies where applicable.
10. Include sufficient detail in the record to allow the patient or client to be managed by another audiologist or speech-language pathologist.
11. Retain records in a manner that allows the record to be retrieved and copied upon request, and in compliance with relevant provincial legislation, regardless of the medium used to create the record.
12. When electronic documentation is used, make every effort to ensure the software used leaves an audit trail that can reveal who accessed the record, what changes were made, when, and by whom.
13. Provide a copy of the clinical and financial record to the patient or client or their authorized representative upon request and appropriate consent, and in compliance with all relevant provincial legislation. Access to test protocols can be restricted due to copyright laws and to maintain test integrity.
14. Secure records during use, while in storage and during transfer, through the appropriate use of administrative, physical, and technical mechanisms (e.g., passwords, encryption, locked cabinets, etc.), and in compliance with all relevant provincial legislation.
15. Ensure the back-up of electronic records to ensure continuity of care in the event records are compromised.
16. Documentation that must be included in the record:
    • Relevant case history information, including health, family, and social history,
    • Evidence of informed consent, where required by relevant provincial legislation, whether that be a signed consent form or documentation of a conversation with the patient or client regarding consent, and the resulting outcome,
    • Presenting concern,
    • Screening and assessment findings, when conducted,
    • Plan of care outlining intervention goals and strategies,
    • Communications with referring providers and care partners,
    • Response to interventions and progress toward achieving goals documented in the plan of care,
    • Recommendations,
    • Referrals to other professionals, reports and correspondence from other professionals and other services provided,
    • Transition or discharge plans, including the reason for discharge,
    • Complete and accurate chart notes that include:
      • Full name and professional designation of the person documenting the information (must be legible),
      • Full name and professional designation of the person taking professional responsibility for the work (if not the person who created the chart note),
      • Names with corresponding titles of assisting professional service providers or support personnel,
      • First and last name of the patient or client, and a tracking number (if one is used) on each page of the chart note,
      • Date that procedures and records were completed,
      • Time that procedures were completed, if clinically relevant,
      • Late entries will include the current date and time, a notation that the entry is late, and the date and time of the events described in the late entry. Appropriate features of the electronic documentation system will be used, as required, to make corrections or late entries. In some situations, this may mean providing an additional entry that is dated for the day the correction is made, indicating which section of the chart note is being revised and why,
      • Amended chart note entries that comply with applicable provincial privacy legislation. If a correction is required, a separate notation in the chart note is made while the legibility of the initial entry is maintained (strike-through is acceptable),
      • Notation of any communication to or with the patient or client, care partners and/or decision-makers, including missed or cancelled appointments, telephone, or electronic contact,
      • Notation of any change in registrant or support personnel (i.e. communication health assistant),
      • Record of any atypical or adverse events during assessment or intervention,
      • Notation that patient or client has been informed of known, publicly funded services and products that can meet their needs,
      • Notation of record closure.

• • Complete and accurate financial records for services rendered or products sold when direct payment occurs. Financial records must include:
    • Patient or client name or identifier,
    • Name and credentials of the professional, including RCASLPNB registration number,
    • Date(s) on which the service was provided,
    • Nature of the service provided (e.g., assessment, treatment, intervention, etc.),
    • Length of time required to provide the service when billed at an hourly rate,
    • The actual fee charged and method of payment,
    • Date payment was received and identity of the payer,
    • Any balance owing or addition of any late fees.

Expected Outcome

Patients or clients can expect their audiology and speech-language pathology records to be clear, confidential, accurate, complete, and maintained in compliance with all relevant provincial legislation.

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Glossary

Adverse event refers to an unexpected incident that occurs during care, treatment, or health related procedures, which negatively affects a patient or client.

Assessment means the formal and/or informal analysis of communication and related disorders to determine the nature, quality, and severity of a delay or disorder and to inform the development of the patient’s or client’s care/management plan.

Bias refers to an inappropriate or unfounded judgment of individuals that may stem from prejudiced beliefs or contribute to the reinforcement of stereotypes.

Care partner refers to an individual who supports someone with a health condition, disability, or other need, often as a member of the care team. They provide physical, emotional, and cognitive support, and are considered vital members of the caregiving process. Care partners can be family members, friends, or other significant individuals in the person's life.

Care pathway refers to a detailed plan that outlines the sequence and timing of interventions for patients with specific conditions or undergoing particular procedures. It acts as a guide for healthcare professionals, promoting consistency and improving the quality of care by ensuring the right steps are taken at the right time.

Chart notes are a component of the patient or client record in which health care providers document essential details of service delivery and interactions, including the individual’s condition treatment plan and progress.

Confidential/confidentiality implies a trust relationship between the person supplying personal information (including health information) and the individual or organization collecting it. The relationship is built on the assurance that the information will only be used by or disclosed to authorized persons or to others with the individual’s permission. Protecting the confidentiality of personal information and personal health information implies that individually identifying information is concealed from all but authorized parties.

Informed consent means that a patient or client agrees to a service after understanding its’ purpose, benefits, risks, and available alternatives.  Informed consent must be obtained when required by relevant provincial legislation and can be withdrawn by the patient or client at any time.

Intervention/intervention strategy refers to the various services provided to patients or clients, including, but not limited to, assessment, individual or group treatment, counselling, home programming, caregiver training, devices, and discharge planning.

Patient or client refers to a recipient of the services of an audiologist or speech-language pathologist.

Record refers to the entire collection of a patients’ or clients’ information over time, regardless of the format or how it is documented, recorded, or stored.

Registrant means an audiologist or a speech-language pathologist and any person whose name is entered in the temporary register or in any of the rosters established and maintained under the Audiology and Speech-Language Pathology Act, the bylaws and rules.

Risk management refers to the identification, assessment, and prioritization of risks followed by coordinated application of resources to minimize, monitor, and control the probability and/or impact of unfortunate events.

Screening refers to a process or tool that is used for the purpose of identifying a possible problem which requires further follow-up, assessment, or referral.

Support Personnel refers to any person carrying out specific tasks constituting part of the practice of audiology or speech-language pathology under the supervision and control of an audiologist or speech-language pathologist, as the case may be, regardless of the job title used

Timely means that something is done promptly or without unnecessary delay.

Click here to view Standard 4.3 Clinical Supervision as a PDF document

Standard

A registrant of RCASLPNB is responsible and accountable for services delivered by support personnel under their direction and supervision, including communication health assistants, speech therapy assistants, rehabilitation assistants, and hearing aid technicians.

Indicators

To demonstrate this standard, the registrant will:

1. Provide pertinent information to the patient or client regarding the support personnel’s role and responsibilities and obtain patient or client informed consent to receive services from the support personnel.
2. Provide adequate on-the-job training and orientation to support personnel as it relates to the clinical and employment context.
3. Optimize both patient or client safety and outcomes by considering the following when assigning clinical activities to support personnel:
   • the competence and scope of practice of the support personnel,
   • resources available to provide guidance, as required (e.g., policies, procedures, availability of senior staff to answer questions),
   • the patient or client’s individual needs,
   • factors unique to the practice environment, and
   • risks associated with the activity.
4. Refrain from assigning activities to support personnel that involve clinical interpretation.
5. Determine, as often as required, the amount of both direct supervision and indirect supervision required for support personnel under one’s direction and supervision. The registrant should have sound rationale to support these decisions and should be able to articulate this rationale as required.
6. Develop a supervision plan for all support personnel in accordance with applicable RCASLPNB guidelines and review and update the plan as needed.
7. Monitor the services provided by support personnel on a regular basis, including patient or client outcomes, and modify or reassign services as needed.
8. Be available for consultation to the support personnel through some mode of communication or develop a plan for supervision coverage when not available (e.g., the plan might include speaking to another registrant to obtain direction, ceasing the activity, or changing activities).
9. Inform employers and patients or clients in a timely manner of the need to discontinue services provided by the support personnel when the audiologist or speech-language pathologist is not available to provide required clinical supervision, and a coverage plan or replacement supervisor is not available (e.g., extended absence, resignation).
10. Maintain responsibility and accountability for support personnel to whom activities have been assigned.
11. Inform the appropriate employer/manager/agency if there are support personnel performance or safety concerns.
12. Refrain from entering into any employment arrangement in which the registrant provides clinical supervision to an individual who is also their employer, regardless of whether the role is paid or voluntary.

Expected Outcome

Patients or clients can expect that services provided by support personnel are appropriately supervised by an RCASLPNB registrant.

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Glossary

Competence/competent/competency refers to the combined knowledge, skills, attitudes and judgment required to provide safe, effective, and ethical professional services.

Direct supervision refers to the supervising audiologist or speech-language pathologist being physically present within the environment or virtually present via real-time videoconferencing. The audiologist or speech-language pathologist observes the support personnel carry out the assigned activity and can provide immediate feedback, redirection, and modeling as necessary.

Indirect supervision refers to the supervising audiologist or speech-language pathologist not being physically or virtually present when an assigned activity is being carried out. The audiologist or speech-language pathologist monitors and evaluates the support personnel’s performance of assigned activities by reviewing audio/ visual recordings, written records, and/or through discussions with the support personnel, patients or clients, care partner, caregivers, team members, and/or employers.

Informed consent means that a patient or client agrees to a service after understanding its’ purpose, benefits, risks, and available alternatives.  Informed consent must be obtained when required by relevant provincial legislation and can be withdrawn by the patient or client at any time.

Patient or client refers to a recipient of the services of an audiologist or speech-language pathologist.

Registrant means an audiologist or a speech-language pathologist and any person whose name is entered in the temporary register or in any of the rosters established and maintained under the Audiology and Speech-Language Pathology Act, the bylaws and rules.

Scope of practice refers to the procedures, actions and services that a health care professional is legally permitted to perform, based on their qualifications, training, education, and licensure.

Supervision refers to a dynamic and evolving process involving the oversight of another’s work. Regardless of the relationship, the purpose of supervision is to help ensure the delivery of competent, safe and ethical audiology and speech-language pathology services.

Support Personnel refers to any person carrying out specific tasks constituting part of the practice of audiology or speech-language pathology under the supervision and control of an audiologist or speech-language pathologist, as the case may be, regardless of the job title used

Timely means that something is done promptly or without unnecessary delay.

Click here to view Standard 4.4 Advertising and Promotional as a PDF document

Standard

A registrant of RCASLPNB ensures that advertising and promotional communications are culturally sensitive, truthful, accurate, and verifiable.

Indicators

To demonstrate this standard, the registrant will:

1. Limit advertising and promotional communication to only that which is relevant to the scope of practice of their profession.
2. Ensure that advertising and promotional communications are a factual and accurate description of the products and services offered.
3. Refrain from guaranteeing the success or superiority of a product and/or service unless the claim is supported by evidence.
4. Refrain from discrediting or diminishing the skills of other providers or the services of other clinics or facilities.

Expected Outcome

Patients or clients can expect that advertising and promotional communications are culturally sensitive, truthful, accurate, and helpful for making informed choices.

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Glossary

Advertising and promotional communications are intended for potential users of a product or service, with the intent of informing or influencing those who receive them.

Culturally sensitive refers to the awareness, understanding, and respectful consideration of the values, beliefs, customs, and practices of people from different backgrounds.  It involves recognizing cultural differences without judgement and adapting behaviours, communication, or services to be inclusive and respectful of those differences.

Registrant means an audiologist or a speech-language pathologist and any person whose name is entered in the temporary register or in any of the rosters established and maintained under the Audiology and Speech-Language Pathology Act, the bylaws and rules.

Scope of practice refers to the procedures, actions and services that a health care professional is legally permitted to perform, based on their qualifications, training, education, and licensure.

Click here to view Standard 4.5 Fees and Billing as a PDF document

Standard

A registrant of RCASLPNB ensures that fees for products and services are justifiable, and that patients or clients are informed of fee schedules before services are provided.

Indicators

To demonstrate this standard, the registrant will:

1. Ensure that fees charged for products and services are justifiable.
2. Fully disclose the fee schedules for products and services including fees for assessment and intervention; reports; equipment and any other associated costs.
3. Obtain and document patient or client consent for fees prior to service delivery.
4. Provide patients or clients with accurate and detailed invoices regarding fees owed and amounts paid in a timely
5. Maintain accurate financial records related to fees and services provided.
6. Correct any fee or billing discrepancies in a timely manner.

Expected Outcome

Patients or clients can expect that fees for products and services are clear and that they will be fully informed about the fee schedules before services begin.

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Glossary

Assessment means the formal and/or informal analysis of communication and related disorders to determine the nature, quality, and severity of a delay or disorder and to inform the development of the patient’s or client’s care/management plan.

Intervention/intervention strategy refers to the various services provided to patients or clients, including, but not limited to, assessment, individual or group treatment, counselling, home programming, caregiver training, devices, and discharge planning.

Patient or client refers to a recipient of the services of an audiologist or speech-language pathologist.

Record refers to the entire collection of a patients’ or clients’ information over time, regardless of the format or how it is documented, recorded, or stored.

Registrant means an audiologist or a speech-language pathologist and any person whose name is entered in the temporary register or in any of the rosters established and maintained under the Audiology and Speech-Language Pathology Act, the bylaws and rules.

Timely means that something is done promptly or without unnecessary delay.