Guidance for Registrants

Why does the College ask registrants so many questions during the annual registration renewal process?

The College’s mandate is to serve and protect the public and, among other obligations, it is necessary for the College to have accurate information about its registrants. The College is obligated to report registration data to the Ministry of Health on a regular basis, and ultimately, patients and members of the public rely on the College’s Public Register for accurate and up-to-date information about chiropodists and podiatrists.

For example, practice data collected in the survey is correlated to a specific practice location, and the College uses this information to direct members of the public and caregivers to the registrants in their geographic region, who offer specific services. This data also allows the College to respond to inquiries from stakeholders and other healthcare providers with greater accuracy and validity. Additionally, having data specific to the services provided at a given practice location allows for more meaningful and effective Practice Assessments by the College and education tools as part of the Quality Assurance Program.

If I take a leave of absence (parental, maternity, sick leave, etc.) can I suspend my membership with the College for that time? Do I need to pay the full renewal fee? 

The College does not have a reduced or pro-rated fee for registrants who are away from their practice during leaves of absence. Registrants must pay for the full renewal year or resign their membership during that time.

If I take an extended leave of absence (parental, sick leave, etc.), what are my obligations to maintain my general certificate of registration?

As required by the Registration Regulation under the Chiropody Act, 1991, if a registrant has not practiced as a chiropodist or podiatrist for a period or periods of at least three months during the previous two years, the registrant is not eligible for registration and shall not engage in the practice of chiropody until the registrant satisfies the Registration Committee that they are competent to do so. Learn more. 

Can I use the title “doctor”, or call myself “doctor” or “doc”? 

No. Registrants cannot use the title “doctor”, a variation or abbreviation or equivalent in another language in the course of providing or offering to provide health care in Ontario by section 33 of the Regulated Health Professions Act, 1991 (RHPA). For more information, see the College’s Guideline for Restriction of the Title “Doctor”. In addition to being professional misconduct, it is also an offence under section 40(2) of the RHPA to contravene section 33 and, on conviction for the offence, individuals are liable to a fine of not more than $25,000 for a first offence and not more than $50,000 for a second or subsequent offence.

Do the rules around the use of “Dr” also apply to clinic names? 

Yes. Registrants must use the appropriate title in the name of their clinic and in any advertising. For example, a chiropodist cannot use the word “podiatry” in a clinic name, unless a podiatrist is practising at the clinic. The College’s Advertising Guideline prohibits advertising statements that are unclear, untrue, or misleading, and section 7(1)(a) of Ontario Regulation 203/94 prohibits statements that are false, misleading, or self-laudatory. If the College is informed about the inappropriate use of titles, the Registrar can consider whether there are reasonable and probable grounds to believe that professional misconduct occurred and to appointment an investigator.

My personal e-mail address contains the word “doctor” or “doc”. Is that allowed? 

Maybe. A registrant who has a PhD or other recognized educational designation is able to use the title “doctor” or prefix “Dr.” in their private, personal communications and so long as that title and/or personal e-mail address is not used in relation to their practice or the course of providing or offering to provide health care in Ontario. Registrants are personally responsible for ensuring their communications and online presence comply with the College guidelines and the restrictions of the RHPA, as it pertains to the use of the title “doctor” and its abbreviations or variants within e-mail addresses, website URLs, and in similar online uses.

What should I do if my patient calls me “doctor”? 

Registrants should clarify with patients that they are not medical doctors, and they are not permitted to use the title or term “doctor” in the course of providing or offering to provide health care in Ontario. When completing any insurance documentation for patients, registrants may use any verified and College recognized academic designations they have obtained, but they must ensure that this documentation also includes their class of registration.

What if my name appears on a website (e.g. websites rating health care providers, social media, etc.) with the title “doctor”? What should I do? 

You must make efforts to ensure accuracy. Under the regulation addressing advertising (O. Reg. 203/94), registrants cannot advertise or permit advertising with respect to their practice that is false and/or misleading. It is professional misconduct to contravene the regulations. Registrants have an obligation to take steps to correct and/or remove any online posts or reviews containing the use of the title “doctor” and its variants and should document their attempts to do so. Registrants are personally responsible for ensuring their online presence meets the College guidelines and the restrictions in the RHPA, as it pertains to the use of the title “doctor” and its abbreviations or variants within any online media.

Can I refuse to see a patient if I don’t think their healthcare needs are serious?

As regulated health care professionals and registrants of the College, it is important to remember that registrants have specialized knowledge and training to address the medical needs of patients’ lower extremity concerns, and it is necessary to evaluate a patient before drawing conclusions about the “seriousness” of their concerns. Registrants also have a duty and legal obligation to provide care to patients without bias or discrimination, and every person has a right to equal treatment with respect to services, goods and facilities, without discrimination because of race, ancestry, place of origin, colour, ethnic origin, citizenship, creed, sex, sexual orientation, gender identity, gender expression, age, marital status, family status or disability.  

Patients contacting your office or clinic to seek care should be provided access to the care you provide without impediment. If there are no further steps you can take to treat or help the patient after initial consultation or assessment, you must communicate this with the patient and/or provide appropriate referrals or advice to help ease the patient’s concerns or questions about their foot health.

What if a patient does not have third-party insurance? 

If a patient contacts your office or clinic to schedule an appointment and is denied care by a registrant because they do not have third-party insurance coverage, this would be inappropriate and a potential breach of the Standards of Practice. How a given patient intends to pay for the services rendered should not be a barrier to obtaining any treatment by a registrant. Denying care to a patient based on their method of payment is not in keeping with the equitable and fair access to care expected to be provided by registrants to all patients.

Could there be a conflict of interest if registrants have a direct financial interest with the orthotic provider/lab?

Yes. Registrants are advised that financial interest might take the form of ownership, business partnership, profit sharing, referral fees, sharing of office space, tenant to registrant owned or leased space and so on. The College’s Conflict of Interest Policy is very clear in the obligations of a registrant in such circumstances:

2. A member shall be deemed to be practicing the profession while the member is in a conflict of interest where a member, or a related person or related corporation, directly or indirectly, (d) makes a recommendation or a referral to a supplier of any service, device, or product in which the member or a related person or related corporation has a financial interest, unless the member at the same time,

i. fully discloses the financial interest;
ii. provides the patient with the name of at least one other supplier in the same geographical area if one exists;
iii. informs the patient that he or she has the option of using an alternative supplier; and
iv. assures the patient that choosing an alternative supplier will not affect the quality of health care services provided by the member; 

Additionally, as part of the annual registration, registrants in such business relationships are obligated to attest to this fact by answering this question:  

“Do you have an interest in any entities that would give rise to a conflict of interest as it is defined in the Conflict of Interest Policy?”

A member has a conflict of interest for the purposes of paragraph 10 of section 2 of O. Reg. 750\93 where the member or a related person or a related corporation has a relationship as a result of which a reasonable person could conclude that the personal interests of the member, the related person or related corporation could improperly influence the member’s professional judgment or conflict with his or her duty to act in the best interests of the patient.

Can a registrant make use of a pedorthist or orthotist’s services to fabricate the orthotics that they can prescribe?   

When considering a potential COI in respect of an orthotic provider or lab, it is important to understand that a COI includes, but is not limited to, serving as a consultant, being an employee, ownership (part or full), shareholder space sharing arrangement, or a contracted position with the orthotic provider or lab. Notably, the reporting requirement is in place even if the registrant is not using the lab as a supplier for orthotics being recommended or prescribed to patients. Accordingly, registrants in such circumstances are obligated to inform the College of the business relationship in writing and, in addition, they must report annually including the details of the business relationship with the orthotic provider/lab at the time of registration renewal. The orthotic provider/lab must also be included by the Registrant as a practice site on the College’s Public Register.

Note: It is insufficient for the registrant to log in to the College website and add the lab as a practice location. Failure to notify the College as outlined above could result in a referral to ICRC. The COI declaration must be documented and included in the medical file every time orthotics are recommended to a patient. It is strongly recommended that this notice be in writing and signed by the patient. This notice is intended to assist registrants in adhering to proper protocols on this important issue. Disciplinary measures have resulted where registrants have failed to disclose such COIs to patients.

What are the general guidelines around prescribing Orthotics? 

The Orthotics Standard, regulations and other standards of the College outlines the College’s expectations around the prescription of orthotics and there is no substitute to reading and understanding all of those requirements. If you have any questions regarding the requirements, please contact the College. Generally speaking:  

1. Registrants may only recommend treatment for orthotics to a patient when there exists a justifiable, medical need for them. Alternate forms of treatments should be considered and attempted by the registrant rather than a demonstrable pattern of default/reflex prescribing of an orthotic for a given clinical presentation. All such findings and treatment plans must be documented in the chart.
2. Registrants may not provide prescriptions for orthotics to be fabricated and/or dispensed by other health care professionals or individuals.
3. The cost for the orthotics, as well as any other ancillary charges, should be provided to the patient in advance of undertaking any such treatment. It is prudent that these costs be provided in writing, along with all other requirements to comply with the provisions of informed consent to treatment.
4. Any billing documentation provided to the patient pertaining to treatments and/or services rendered must identify the registrant by name, class of registration (chiropodist or podiatrist) as well as the practice location contact information.
5. Registrants are obligated to fit and dispense the orthotics to the patient for which they prescribed the orthotic in person. In certain circumstances, it is also permissible for another registrant of the College to dispense the orthotic to that patient.
6. Registrants are obligated to schedule a follow-up appointment post dispensing to assess the patient’s progress with the orthotics and evaluate and/or modify the treatment plan. 

What is the Prescription Custom Foot Orthotics (PCFO) Standard?

The Prescription Custom Foot Orthotics (PCFO) Standard provides clarity on the prescribing and dispensing of PCFO by registrants. It sets out the standards of the profession and to ensure that the public of Ontario have access to safe and effective PCFOs by: 

• Providing clearer language and definitions within the Standard; 

• Amending the requirements related to prescribing, casting and dispensing to ensure better continuity of care; 

• Expanding on the requirements for documentation related to PCFO to make clearer the need, goal(s) and efficacy of a PCFO; 

• Standardizing the requirements for follow-up appointment(s) after PCFO are dispensed to ensure optimal functioning of each PCFO; 

• Standardizing the requirements for expectations of treatment and patient dissatisfaction to better inform and empower patients as active members of their own health care team; and, 

• Improving access to PCFO and ensuring patient safety by defining a limited timeline in which a patient may have a PCFO re-dispensed without the need for a full reassessment. 

Is there a limit to how many custom orthotics a registrant can prescribe? 

Yes. Registrants may only recommend treatment for orthotics to a patient when there exists a justifiable, medical need for them. Alternate forms of treatments should be considered and attempted by the registrant rather than a demonstrable pattern of default/reflex prescribing of an orthotic for a given clinical presentation. All such findings and treatments must be documented in the chart. Registrants may not provide prescriptions for orthotics to be fabricated and/or dispensed by other health care professionals or individuals.

Can registrants routinely perform biomechanical examinations and gait analyses?

No. Biomechanical examinations and gait analyses, in their entirety, must only be performed by a registrant when required as part of determining the appropriate prescription for the orthotic. The biomechanical examination and gait analysis should not be performed, nor should the patient be billed for a biomechanical examination and gait analysis, until the medical need for treatment with a custom orthotic has been properly established and the patient has consented to the treatment plan. Overutilization of these assessments and billing for services that are excessive and/or not medically necessary is professional misconduct with the meaning of the Professional Misconduct Regulation.

Can I mail a PCFO to patients, or leave orthotics at the front desk for patients to pick up?

No. The standards require that the PCFO is dispensed by a registrant who prescribed the orthotics. Dispensing includes inspecting the PCFO to ensure it meets the prescription, fitting the PCFO on the patient, and educating the patient on the proper use of the PCFO. These processes can only be done in-person by the prescribing registrant (or another registrant if the prescribing registrant is unable to dispense the PCFO). 

Registrants are obligated to schedule a follow-up appointment to assess the patient’s progress with the orthotics. 

Can I delegate the dispensing of PCFO to clinic staff members or assistants? 

No. PCFO must be dispensed by a registrant. Best practice requires that the PCFO is both prescribed and dispensed by the same registrant; however, in certain circumstances, another designated Registrant may dispense the PCFO to the patient.

I performed a PCFO assessment on a patient. They are now requesting a copy of their prescription to take elsewhere. Do I need to provide it to them? 

Before proceeding with any assessment or treatment, registrants need to first have a conversation with their patient explaining the assessment and treatment plan and obtaining appropriate consent from the patient. As always, such discussions with the patient should be properly documented in the patient’s records. In the case of orthotic management, patients need to understand from the outset that registrants are unable, in accordance with the College’s standards, to merely provide an orthotic prescription. Additionally, the registrant should not initiate a biomechanical examination for prescribing a PCFO until the patient has first consented to proceeding with this treatment plan with the registrant. Registrants need to explain that they have a professional obligation to provide comprehensive care to the patient, and that includes conducting a thorough assessment, dispensing of the orthotics, and providing follow-up management. This continuity of care is consistent with best practices and the requirements of the standards.

In accordance with section 18 of Ontario Regulation 203/94 (and other legislative requirements), registrants are required to provide a patient with access to or a copy of the patient’s records as provided for in the regulation. However, this does not entitle a patient to an original prescription for orthotics to take elsewhere.

According to the PCFO Standard, the orthotic prescription is defined as the set of instructions intended for the orthotic laboratory that very specifically outlines the parameters of design, composition and fabrication of the orthotic. If the orthotic prescription is already part of a patient’s record, then access to or a copy of the prescription must be provided to the patient upon request. However, if the orthotic prescription has not been completed at the time of the patient’s request, it is not part of the record and there is no obligation for the registrant to provide a prescription. But again, to avoid any misunderstandings, patients need to be advised about the registrant’s obligations from the outset – before any assessment is conducted and a prescription is prepared.

I prescribed orthotics to my patient and after a year they want another pair. Can I dispense a pair using the same prescription?

No. A new assessment and prescription is required. In appropriate circumstances, a prescribing registrant may re-dispense a PCFO to a patient within one year of the original orthotic prescription without the requirement for a full patient assessment.

Can registrants conduct in-office analyses for fungal infection of toenails?

No. The collection and/or testing of tissue samples (including nails) are regulated activities in Ontario and only certain regulated health professions in Ontario and/or licensed facilities are permitted to engage in those activities. Chiropodists and podiatrists do not have authority to:   

1. Collect tissue or fluid specimens, or  
2. Submit specimens for lab analysis.

Registrants are encouraged to contact the College on matters about the scope of practice when they have questions or are uncertain about a matter to ensure that they are in full compliance with the Standards of Practice.

If a specific drug is not listed in the approved drug list, can a registrant still prescribe it to patients?

No. Registrants may only prescribe drugs included in the approved drug list, if they have the appropriate prescribing privileges. Registrants are encouraged to frequently check the lists of drugs included in the Drug Regulation and are cautioned against prescribing any medications that are not on the current drug list. Prescribing unauthorized or unapproved drugs could lead to a complaint against the registrant for breach of the Standards of Practice.

What are the rules around the use of lasers to treat fungal toenails?

In December 2019, Health Canada issued the following advisory: 

“Health Canada is clarifying that, while some laser-based medical devices are licensed in Canada to temporarily increase the clarity of the nail in patients with a fungal nail infection, none have been licensed to cure these infections.”

When communicating with patients considering the use of lasers to treat fungal nail infections, registrants should only make claims as to outcomes consistent with this advisory and should not promise or promote any results beyond what is stated in the advisory. Additionally, it is advisable that registrants consider and have ruled out with appropriate referrals for testing and analysis, all other differential diagnoses before recommending treatment for suspected fungal nail infections (onychomycosis) with this modality or any treatment plan.

What are registrants’ obligations with respect to insurance claims and billing documents?  

Registrants must ensure that they are clearly identifying their class of registration, (chiropodist, or podiatrist), as part of any and all documents provided to patients, or submitted directly to third-party insurance providers, to fully comply with the College’s legislation, standards and guidelines. This is to prevent confusion around registrants’ claim forms and billing documents submitted to insurers for services rendered. To assist registrants, the College has a Fees, Billing and Accounts Guideline.

Can chiropodists and podiatrists bill for additional services such as nail polish application provided by an aesthetician or nail technician?

No. Registrants should only bill for services they personally perform, and those services are required to be medically necessary. Registrants are not permitted to provide or bill for any product or service that is not medically necessary and, to do otherwise, constitutes a conflict of interest and professional misconduct.

What are the rules around billing for footcare treatments/services conducted by nurses and other healthcare providers pursuant to an order by a registrant?

As set out in the College’s Assignment, Orders and Delegation Policy, a registrant may, assign to an individual, employed or engaged within the member’s practice, acts within the practice of chiropody which are not controlled acts, provided the member assigning the act is satisfied that the person has the knowledge, skill and judgment to safely and effectively perform those acts. The member who assigns these acts retains full responsibility and accountability to the patient for the performance of those acts.

In addition, under the Nursing Act, 1991, nurses registered with the College of Nurses of Ontario are authorized to perform certain controlled acts where a registrant has provided the nurse with an order to perform that act for one of the registrant’s patients, in certain circumstances.

An order may be given either orally or in writing. However, where an order is given orally, details of the order must be written into the patient’s chart. A written order should be recorded either in the registrant’s chart for the patient or a copy of the order maintained with that chart.

Can registrants bill services provided by an RN (for example, wound care or monitoring a patient’s vital signs while that patient was having nitrous oxide administered) under, “Chiropody Services”?

No. Registrants cannot bill for services provided by an RN or another colleague or staff member and can only bill for the services they directly provide to patients. To do otherwise could be viewed as a breach of two provisions of the Misconduct Regulation:
18. Falsifying a record relating to the member’s practice
21. Submitting an account or charge for services that the member knows is false or misleading.

Should the patient be notified about the costs for custom orthotics and other treatments beforehand?

Yes. The cost for the orthotics and any other ancillary charges should be provided to the patient before undertaking such treatment. It is prudent that these costs be provided in writing, along with all other requirements to comply with the provisions of informed consent to treatment.

Any billing documentation given to the patient pertaining to treatments and/or services rendered must identify the registrant by name, class of registration (chiropodist or podiatrist) and the practice location contact information.

What are the College’s expectations with regard to a specific clinical biohazard policy and a sharps policy?

The College has an Infection Control Standard. Page 14 provides detailed information on this topic:

“Waste from any clinical office setting is divided into two categories: biomedical and general. Management of contaminated infectious waste shall follow provincial regulations and local bylaws and address issues such as the collection, storage, transport, handling and disposal of contaminated waste, including sharps and biomedical waste. Waste shall be contained in a securely closed plastic bag of sufficient thickness to prevent puncturing. Contaminated sharps, such as needles, scalpel blades and other instruments must be considered potentially infective and hence, handled with extreme care. Precautions should be taken when passing instruments and removing blades from scalpel handles to avoid needlestick/sharps injuries. Needle recapping should be avoided. Single use, safety-engineered needles are mandated according to the Needle Safety Regulation (O. Reg 474/07)”.

In most instances, items such as gauze, cotton rolls and examination gloves that have come in contact with blood, saliva or other bodily fluids are NOT classified as biomedical waste. Provided that the item does not release liquid or semi-liquid blood if compressed, it should be considered as general office waste. Handling of removed or partial toenails relating to “nail surgeries” do not require any special considerations for IPAC, other than simple cleaning of visible blood and gross debris. If discarded, avulsed toenails may be disposed of as general office waste.

For the purposes of Infection Prevention and Control (IPAC), “biomedical” and “general” waste are defined as follows:

Biomedical waste: Biomedical waste is classified as hazardous waste and must not be disposed of with regular garbage. It must be handled safely to protect human health and the environment. In general, all biomedical waste must be stored in colour-coded containers that are marked with the universal biohazard symbol; and released to an approved biomedical waste carrier for disposal. Biomedical waste can be further divided into anatomical and non-anatomical waste.

1. Anatomical waste (i.e. human tissue) 
2. Non-anatomical waste (i.e. sharps and blood-soaked materials).

It would be highly unusual for registrants to be harvesting anatomical waste. This waste must be handled in accordance with Ontario Regulation 347: General – Waste Management. Non-anatomical waste includes sharps (e.g. surgical blades, needles, clinical glass) which many registrants will have. Non-anatomical waste includes blood-soaked materials that release liquid or semi-liquid blood if compressed. It must be separated and collected in a YELLOW liner bag that is labelled with the universal biohazard symbol. If blood-soaked materials are to remain on site for more than four days, they must be handled in accordance with Ontario Regulation 347: General – Waste Management. Review the Best Management Practices for the Disposal of Biomedical/Pathological Wastes in Ontario.

General office waste: General office waste is no more infective than residential waste. Therefore, most soiled items generated in clinical settings do not require any special disposal methods, other than careful containment and removal. Some recommendations for all types of general office waste include the following:

• Ensuring all garbage containers are waterproof and have tight-fitting lids, preferably operated by a foot pedal.  

• Using plastic bags to line the garbage containers as open wastebaskets might be dangerous if children are around them. Double bagging is not necessary, unless the integrity of the bag is jeopardized, or the outside is visibly soiled.  

• Not overfilling garbage containers and not placing sharp, hard or heavy objects into plastic bags that could cause them to burst.

The inclusion of a “sharps policy” is a requirement of any practice assessment as it is part of the Safety and Practice Environment Standard. Therefore, registrants must ensure they have a sharps policy reflective of IPAC standards and local and clinical factors, and IPAC requires that registrants have a policy or policies on the handling of biohazardous waste. Find more information in the IPAC Program Standard. 

What are a registrant’s obligations with regards to discontinuation of services?

The Discontinuation of Services Advisory discusses important considerations and a registrant’s responsibilities that are associated with the discontinuation of services or practice closure arising from retirement, resignation, extended leave of absence (such as maternity/parental leave, sick leave, etc.), revocation, suspension, incapacity, or death.

However, a registrant may need to discontinue services for other reasons, and the policy still applies. Registrants may face unique or unforeseen circumstances that lead to a breakdown in the registrant-patient relationship, such as verbal abuse from patients or miscommunication between registrants and/or clinic staff.

While the circumstances are unique and different than those identified in the Advisory, the fundamental obligations are the same. Registrants must provide thorough documentation outlining the circumstances of the discontinuation of services. Documentation must include details outlining the steps the registrant has taken to inform the patient(s) of practical alternate options for the provision of care by registrants of the College. Registrants have responsibilities under the Records Standard regarding records retention even after a patient leaves the clinic.