Scope of Practice, Supervision, and Delegation
Domain 2 - Scope, supervision, and delegation
This domain tests the boundary between what a PT may do independently, what a PTA may do under supervision, and what may be delegated to unlicensed aides. Hawaii answers come from HRS 461J and HAR 16-110, not from generic professional guidance.
PT scope and direct access
- Physical therapy includes examination, evaluation, treatment, and instruction to prevent or limit disability, movement dysfunction, and pain. It uses therapeutic exercise, physical agents, manual therapy, mechanical devices, and related tests. PTs do not perform surgery or practice medicine; they evaluate and treat within the PT scope and refer outside it.
- Hawaii permits limited direct access: a PT may evaluate and treat without a physician referral, but must refer the patient to an appropriate licensed practitioner if the condition does not improve within 30 days or if red flags appear. Insurance and employer policies may still require a referral.
- PTs must obtain informed consent, document the plan of care, and reassess objectively.
Supervision and delegation
- A PTA is licensed and implements the PT’s plan of care. The PT performs the initial examination and evaluation, establishes the plan, and remains responsible for reassessment and discharge. A PTA may not independently evaluate, establish or substantially alter the plan, or perform procedures outside PTA scope.
- Hawaii rules require the supervising PT to provide the level of supervision the rule specifies-commonly direct, on-site supervision with the PT physically present and available for consultation. The PT must be reachable and must not supervise more assistants than the rules allow.
- Unlicensed aides may perform non-skilled tasks such as transport, cleanup, clerical work, and equipment setup, but may not apply modalities, instruct therapeutic exercise, or make clinical decisions. Delegation does not transfer accountability.
Worked example
A clinic owner asks a PTA to perform an initial evaluation on a new knee-pain patient while the PT is at a second site, then asks an aide to apply ultrasound. Neither is permissible. The initial evaluation and plan are PT functions; the PTA may treat only after the PT’s evaluation and under the required supervision. Ultrasound is a skilled intervention and cannot be delegated to an aide. Reasoning: licensure and supervision rules attach to the task, not to the clinic’s staffing convenience.
Traps
- Treating “direct access” as “no referral ever.”
- Letting a PTA do the initial evaluation or discharge.
- Calling an aide a “tech” to avoid supervision rules.
- Assuming a signed plan of care permits unlimited delegation.
- Ignoring the 30-day referral trigger or red flags.