Clinical governance: sequenced functional assessment

01Purpose and scope

This protocol governs a functional assessment in which a person performs ordinary daily tasks in a realistic sequence, rather than in isolation, with structured follow-up afterwards.

It applies to every sequenced assessment, for every client.

It does not govern the records audit, which involves no contact with the person and carries no clinical risk.

Why a protocol is needed at all. A standard functional capacity assessment tests discrete tasks and stops. This assessment deliberately accumulates load across a sequence and then documents the consequence. That is what makes it evidentially useful, and it is also what makes it a clinical intervention with foreseeable adverse effects. An assessment that harms the person is a clinical failure first and an evidentiary failure second. The harm is the reason for the governance; the fact that a Tribunal will ask about it is secondary.

The order of priority, stated once so it governs every judgment below. Where the safest course and the most useful evidence point in different directions, the safest course wins, and the report records that a safer course was taken and why. A finding that a person could not safely be assessed by exertion is itself evidence, and section 6.6 explains why it is often stronger evidence than the assessment it replaces.

02The reference standards this protocol adopts

Australia has no current clinical guideline for ME/CFS: the national guidance dates from 2002, and Emerge Australia's position is that it recommends approaches now understood to cause harm. This protocol therefore adopts the following as its reference standards and says so openly, so that a reviewer can test the choice rather than guess at it.

Where a standard is updated, section 13 requires this protocol to be reviewed against it.

Instruments deliberately not used. The 10-Minute NASA Lean Test is not part of this screen. It cannot be reliably administered by video, it requires equipment most people do not have, and its own stopping rule assumes someone is close enough to catch the person. Orthostatic risk is instead picked up through the falls screen and the history, which is sufficient for the purpose this screen serves: deciding whether an assessment is supervised, not diagnosing dysautonomia.

03What the assessment involves

• A sequence of ordinary daily tasks performed in a realistic order. Indicative sequence: rising and bed transfer, personal hygiene, dressing, meal preparation, a household task, a mobility component
• One hour maximum per session, including rests. The session ends at one hour whether or not the sequence is complete, and what was not reached is recorded and stated in the report
• Rests taken as needed and recorded. Nothing is timed against a target
• Observation of what is attempted, what is modified, what is abandoned, and what is left undone
• Structured follow-up after the assessment: see section 8

The interview and history that precede it are a separate session on a separate day, and section 5 explains why that is a safety mechanism rather than a scheduling preference.

The assessment does not push to failure. It sequences ordinary activity and records what that costs. The distinction is not rhetorical: it determines the consent, the stopping rules, and the risk profile, and section 7.3 makes it structurally true rather than merely stated.

04Foreseeable risks

Post-exertional malaise. In ME/CFS, long COVID and some overlapping presentations, cumulative activity can provoke a disproportionate deterioration. Onset may be immediate or delayed by a day or more, and recovery may take days, weeks or months. This is the most serious foreseeable harm in this protocol, it is not reliably visible on the day, and section 6.6 sets out how it is identified, which is not by asking how tired someone gets.

Flare. A shorter, self-limiting increase in pain and dysfunction. Common, expected, and part of what the follow-up exists to document, but it must be anticipated rather than discovered.

Falls. Sequenced mobility, transfers and household tasks, in a population with reduced tolerance and often reduced balance, in a setting where the assessor cannot physically intervene.

Cardiovascular and respiratory events. A deconditioned population, sometimes older, sometimes with comorbidity documented in the file but not volunteered in conversation.

Orthostatic intolerance and syncope. Relevant in dysautonomia and POTS presentations, and to anyone whose sequence involves repeated position change.

Joint instability. Subluxation or dislocation risk in hypermobility spectrum presentations, including hEDS.

Psychological distress. The assessment asks someone to demonstrate what they can no longer do, in their own home, for a purpose that matters enormously to them. That is confronting independent of any physical consequence, and for some people the demonstration itself is the harm.

Incentive pressure, and this one is specific to the setting. The person knows the assessment bears on an outcome they need. That creates pressure in both directions: to underperform, and to push through and prove they tried. Both threaten the validity of what is recorded and both are a welfare risk.

Incentive pressure applied to the screen itself. A person who wants to be assessed has a reason to under-report falls, syncope or bad days, particularly if an honest answer means being told they need a support person they do not have. A screen that is purely self-report, given to someone with a strong incentive to pass it, is not a safeguard. Sections 5 and 6.2 are the answer.

05Three stages, on three different days

This is the architecture the rest of the protocol depends on, and it is the reason the screening works. Risk is not discovered on the day of the assessment by a questionnaire. It is built up across three separate contacts, each of which can stop the process.

Stage 1 · The records audit: before any contact

The audit comes first, always. By the time Simon speaks to the person he has their imaging, correspondence, discharge summaries, specialist letters and treatment history in front of him.

Most of the risk in this protocol is identified here, before the person has answered a single screening question. Uncontrolled cardiac or respiratory disease, a documented ME/CFS or long COVID diagnosis, a history of syncope, recurrent dislocation, a fall requiring presentation: these are in the file. The audit produces a preliminary risk list that is carried into stage 2.

Stage 2 · The subjective interview: a separate session, a separate day

Method step 5. A structured clinical interview, conducted by video, on its own day.

Its screening function is twofold, and both directions matter:

• It confirms what the audit found. A file entry is not a current clinical picture. A dislocation recorded four years ago may be monthly now, or may not have recurred.
• It catches what the audit missed. Falls that were never presented to anyone. Syncope managed at home. A pattern of post-activity collapse that no clinician has ever asked about, which is extremely common and is exactly what section 6.6 turns on.

The screening conversation happens here, informed by the preliminary risk list rather than starting from nothing. Consent is taken at this stage, not on the day of the assessment. Nobody signs consent for a procedure immediately before undergoing it.

The tier is assigned at the end of stage 2, and where GP clearance is required (6.3), it is requested here. The gap between sessions is what makes that possible.

Stage 3 · Pre-assessment confirmation: on the day

Short, and limited to what can only be known on the day:

• Are you in a flare today, or have you been in the past seven days?
• Is today representative?
• What did you do yesterday, and what has it cost you today?
• Has anything changed since we spoke: new symptoms, new medication, a fall?
• Confirmation of identity, address, and who is present

Any material change reverts to stage 2. The assessment is rebooked, not modified on the spot.

Why this matters

Three contacts on three days, with a complete medical record read before the first of them, is a fundamentally different screening instrument from a form filled in before an appointment.

It means the person is not being asked to self-assess cold; they are being asked to confirm or correct a picture already built from their own records. It means a discrepancy between what the file says and what the person says is visible, and is treated as clinical information rather than as dishonesty, because people under-report for reasons that are usually understandable and sometimes evidentially significant in their own right. And it means there is always a gap in which a GP clearance can be sought without anybody being rushed.

Where the file and the person disagree, the more conservative position governs, and the discrepancy is discussed, recorded, and stated in the report.

This should be described in every report. It is the answer to the question of how a video assessment can be safely screened, and it is available only because the audit comes first.

06Screening and clearance

6.1 · What the screen is for

The screen does not decide whether the person is unwell enough to need an assessment. It decides one question: what supervision this assessment requires, and whether it should happen at all.

That distinction matters in this population. Almost everyone Simon assesses will screen positive on something: most will report post-exertional fatigue, many will have a positive falls screen, many will have an orthostatic history. A screen that treats any positive as an exclusion sorts nobody and helps nobody. The screen has to separate the risk that changes what is done from the risk that is simply the reason the person is here.

6.2 · Screening is outsourced where it needs to be

Several of the instruments in section 2 cannot be validly administered by video, and none of them should be self-scored by a person with an incentive in the result.

Where any clearance indication is present (6.3), the screening is completed by the treating doctor, not by Simon and not by the person. The clearance request asks the GP to complete the PAR-Q+ and the Stay Independent questionnaire and to provide written clearance.

This is the right answer for four reasons, and they compound:

1. The GP can examine the person. Simon cannot, by video.
2. The GP holds the record and knows the trajectory: which conditions are controlled, which are not, and what has changed recently.
3. It removes the incentive problem entirely. The person is not scoring themselves.
4. It puts the decision with the clinician who carries the ongoing relationship, which is where a decision about whether exertion is safe for this person properly sits.

The cost is a third party in the booking pathway and a delay of some weeks. That cost is accepted. The three-stage structure at section 5 absorbs it, because the clearance is requested at stage 2 and the assessment is not booked until it arrives.

6.3 · The clearance gate

Where any of the following is present, no sequenced assessment proceeds until written GP clearance is held.

• A diagnosis of ME/CFS, or long COVID with post-exertional symptom exacerbation
• A positive PEM pattern on the criteria at 6.6: duration, onset and disproportionality, not severity
• Any indication of uncontrolled cardiac, respiratory or metabolic disease: from the audit, the interview, or a PAR-Q+ response
• Syncope or near-syncope within the preceding twelve months
• Dislocation requiring reduction within the preceding six months
• Any judgment under 6.5 that the assessment is likely to be destabilising
• Any other risk the audit or interview raises that Simon judges warrants a second clinical opinion

What the clearance request contains. Not a form asking "is this person fit for exercise." The request describes the protocol: that tasks are sequenced rather than isolated, that the assessment is by video, that a support person will be present, that symptoms may worsen and may stay worse, and what the stopping rules are. A GP cannot clear something they have not been told the shape of, and a clearance obtained on a vague request is worth nothing to anybody.

It asks the GP to complete PAR-Q+ and Stay Independent, and to state in writing whether the person may undergo the assessment as described.

Three outcomes:

Clearance permits; it does not compel. Simon retains the right to decline to proceed notwithstanding written clearance, where his own judgment is that the assessment is unsafe or that the GP has not understood what was being asked. That decision is recorded with its reasons. A clearance letter is not a transfer of responsibility: under Ahpra's guidance the care delivered remains the delivering practitioner's.

6.4 · Supervision tiers

Assigned at the end of stage 2, and recorded.

Tier B: supervised. A support person is present in the room for the duration and is briefed under 9.3. High-risk tasks are excluded or performed with physical standby (9.5).

This is the default for this population, and it is expected to apply to most people. It applies to anyone who has come through the clearance gate, and to anyone with:

• A positive STEADI screen, or Stay Independent ≥ 4
• Orthostatic symptoms on history: lightheadedness, visual change, palpitations or nausea on standing
• Any PAR-Q+ positive cleared with conditions
• Beighton ≥ 5, or recurrent subluxation
• Any prescribed medication with sedative, hypotensive or vestibular effect
• Age 65 or over
• Any single concern that does not reach the clearance gate but that Simon judges warrants standby

Tier C: reachable third party. A support person is recommended, not required. The sequence is limited to the low-risk set at 9.5, and a named third party must be contactable throughout and able to attend quickly.

Tier C applies only where the audit and the interview are negative across every domain above, and where no clearance indication was present. It is expected to be uncommon, and that is the correct result rather than a design flaw.

Deferred. An acute flare now or within the preceding seven days defers the assessment. It is rebooked, not modified.

6.5 · Psychological safety, within scope

Simon is a physiotherapist. This section does not authorise psychological assessment and does not produce a psychological finding.

What it requires is a documented judgment, before the assessment, on whether demonstrating loss of function is likely to destabilise this person, informed by the file, by the treating team's correspondence, and by how the person presents across stage 2. Where the answer is yes, or unclear, the clearance gate applies and the reason is recorded in general terms.

Where distress emerges during the assessment, section 7.1 applies and the assessment stops.

6.6 · Post-exertional malaise: identified by duration, not by severity

This is the most consequential clinical judgment in the protocol and the easiest one to get wrong, so the reasoning is set out in full.

The DSQ-PEM core items ask how tired, drained or sore a person is after minimal activity. In a chronic pain population, almost everyone scores highly on them. Post-exertional fatigue is close to universal here. Using those scores as a threshold would exclude nearly every person this practice exists to serve, and would exclude them for a reason that does not distinguish the dangerous case from the ordinary one.

What distinguishes post-exertional malaise from ordinary post-exertional fatigue is not how bad it feels. It is three other things:

1. Duration. Symptoms persisting more than 24 hours after ordinary activity. This is the threshold used across the diagnostic frameworks: Fukuda specifies fatigue for 24 hours or more after exercise, and the Canadian Consensus and IOM/SEID criteria treat prolonged recovery as the hallmark. After maximal exercise testing, one study found 60% of ME/CFS patients needed more than five days to recover, against two days for controls.
2. Delayed onset. Symptoms that begin hours or a day or more after the activity, rather than during it or immediately after. Up to 37% of patients report onset delayed by a day or more. Ordinary post-exertional fatigue does not behave this way.
3. Disproportionality. Triggered by activity that would otherwise be tolerable: showering, preparing a meal, reading. In ordinary exercise intolerance, severity tracks intensity. In PEM it does not.

The rule. The clearance gate is triggered by any of:

• Reported symptom duration exceeding 24 hours after ordinary daily activity
• Symptom onset delayed by several hours or more after activity
• Crashes triggered by minimal activities of daily living
• A diagnosis of ME/CFS, or long COVID with post-exertional symptom exacerbation

Elevated DSQ-PEM core item severity, on its own, triggers nothing. It is recorded because it is clinically relevant to the report, not because it decides anything about safety.

Why the gate rather than an exclusion. NICE NG206 withdrew graded exercise therapy for ME/CFS, and Emerge Australia's position is that cardiopulmonary exercise testing triggers PEM and risks an overall worsening. A sequenced assessment is not CPET, but it shares the feature that matters: it accumulates load and documents the consequence. That is a serious enough risk that it should not be taken on Simon's judgment alone, by video, on the strength of a questionnaire. It should be taken, or declined, by the doctor who knows the person, in writing, having been told exactly what is proposed.

That is what the clearance gate is for. It is not a way of getting to yes. In this group it will often produce a no, and 6.7 explains why that is a good outcome for the person.

6.7 · What happens instead

Nobody who does not proceed is left without evidence.

1. The records audit, which is already complete
2. The Pain, Sleep and Fatigue Diary, which produces countable frequency and duration data over a defined period without any exertional challenge. Where the person has kept one, it also supplies the 6.6 criteria prospectively rather than by recall: runs of hard or bed days give duration, the delayed-exacerbation column gives delayed onset, and the activity line gives disproportionality
3. Structured history and collateral report from a family member or support worker who observes the person across whole days
4. A referral recommendation where the file needs an assessment outside physiotherapy scope

And the decision itself is recorded as a finding. A documented conclusion that a person cannot safely undergo a sequenced functional assessment (with the reasoning, and where applicable a treating doctor's written refusal to clear them for ordinary sequenced daily tasks) is a clinical finding about the severity and permanence of their condition.

In the right case that is stronger evidence than the assessment it replaced. A GP letter declining to clear someone for a sequence of ordinary household tasks says something about functional capacity that no assessment of that person could have said better, and it exists only because somebody applied a gate and wrote down the result.

07Conduct of the assessment

7.1 · Stopping rules

Defined in advance, applied by the assessor, and recorded when used.

The assessment stops immediately where any of the following occurs:

When a stopping rule is applied it is recorded: what triggered it, at what point in the sequence, what was done, and what happened next. Applied stopping rules appear in the report.

7.2 · Monitoring

The assessor observes continuously and checks in verbally at defined points in the sequence, not only when something appears wrong. A person under incentive pressure will not reliably volunteer that they are struggling, and at Tier B the support person is briefed to say so if the person will not.

Pain is rated at baseline, between each task, and at the end. This is the data the follow-up is compared against.

7.3 · The assessor does not encourage continuation

No "can you manage one more." No timing against a target. No comparison to what others manage. No suggestion, in any form, that a completed sequence is a better outcome than a stopped one.

The sequence is ordinary activity performed in order. The moment it becomes a test of endurance, the protocol has been breached, and a breach is recorded as an adverse event under section 10 even where nobody is harmed, because the validity of the assessment has been compromised.

If the person cannot complete the sequence, that is a finding, recorded as one, and the assessment ends.

08Follow-up

A single 24-hour call is not sufficient. PEM onset can be delayed by a day or more. A flare can outlast a day. A follow-up that closes at 24 hours will miss both, and will miss them in exactly the population most at risk.

Three contacts, all structured, all recorded:

Where the 7-day contact reports ongoing deterioration, contact continues at weekly intervals until baseline is regained or the person declines further contact, and section 10 applies.

Every contact is also a welfare check and is treated as one. The clinical purpose comes first; the evidentiary record is a by-product of doing it properly.

The public pages name these intervals, decided 14 September. Method step 9 and the assessment safety page state them as they appear here; Home §5 and Services §7 say "the next day, three days later, and a week later". If this section changes, all four pages change with it.

09Video delivery

The sequenced assessment is conducted by video. In-person assessment is not offered.

That preserves national reach and keeps the assessment accessible to people for whom travel is itself a barrier, which, in this population, is not a small consideration. It also removes the assessor's ability to intervene physically, and the conditions below are what make video defensible rather than merely convenient.

9.0 · The regulatory position, stated accurately

There is no separate telehealth guideline for physiotherapists. The Physiotherapy Board's position is that virtual care relies on the existing regulatory framework (the Code of conduct, registration standards, and Ahpra's virtual care resources) rather than on a distinct set of rules. Ahpra's telehealth guidance, updated in October 2025, requires practitioners to confirm the person's identity, obtain informed consent, gather sufficient history, and tell the person where telehealth may not meet their needs. Responsibility for care delivered by telehealth sits with the practitioner and is not transferred to anyone else.

The practical consequence for this protocol is that the standard is the ordinary standard of care, delivered remotely. Sections 9.1 to 9.7 are what meeting it looks like here.

9.1 · Identity and location

Identity is confirmed at the start of every call.

The address is confirmed verbally and recorded, every time, so that emergency services can be directed without delay. An assessment does not begin until the address is confirmed and correct.

9.2 · A reachable third party: the floor, at every tier

At Tier B, a support person is present in the room for the duration.

At Tier C, a named third party is identified beforehand and is contactable throughout, by phone, and able to attend within a short period. Their name and number are recorded.

There is no tier at which a person performs a sequence alone and uncontactable. The support-person requirement flexes with risk. This one does not.

An emergency contact is identified before every assessment, at every tier, whether or not it is the same person.

9.3 · The support person is briefed, not just present

At Tier B, before the sequence begins, the support person is told:

• What the sequence involves and where standby is required
• That they should intervene physically if they judge it necessary, without waiting to be asked
• That they should say so if they think the person is struggling and not saying so
• That they may stop the assessment themselves, and that doing so is a finding and not a failure
• That they are not being assessed, and that nothing they do will count against the person

Their presence, their name, and their relationship are recorded and stated in the report.

9.4 · Orthostatic risk

Screened on history and through the falls screen, not by instrumented testing. Where a person's history indicates orthostatic intolerance, either the position-change components of the sequence are performed with the support person on physical standby, or they are removed.

Where a component is removed, the report says which, and why. An untested capacity presented as an intact one is the failure this protocol exists to prevent.

9.5 · Task exclusions

Excluded from every video sequence, at every tier:

• Anything performed at height: steps beyond a single stair, ladders, stools, reaching above the head from an unstable base
• Anything involving water where a fall is possible: showering, bathing, wet floors
• Anything involving heat: stovetops, ovens, kettles, hot liquids carried while mobilising
• Sharp implements used while standing or while fatigued
• Any task the person identifies as one they have fallen doing
• Any task requiring the person to be out of camera view

Where an excluded task is central to the evidence, it is addressed by history, by the diary, and by collateral report, and the report states plainly that it was not observed and why. An unobserved task reported as observed is the single most damaging thing this practice could do.

Permitted at Tier C, in addition to the standard sequence: seated tasks, standing tasks with a stable surface within reach, transfers with a stable surface within reach, and mobility within a familiar space.

Tier B adds the requirement that the support person is within arm's reach for every transfer, every standing task, and every mobility component.

9.6 · Observation quality

Camera position and observation quality are established before the sequence begins. The assessor confirms aloud that the person is adequately visible for the task about to be performed.

Connection failure is a stop. The sequence does not continue while the assessor cannot see. If the connection cannot be restored promptly, the assessment ends and is rebooked; the interrupted sequence is recorded and is not presented as complete.

9.7 · The evidentiary consequence, stated honestly

A published decision discounted a telehealth occupational therapist's evidence for three reasons: no personal observation, information obtained from conversation only, and unavailability for cross-examination.

Two of those three do not apply here. This assessment is observation-based rather than interview-based, and the assessor is available to be questioned. But the criticism is available against every video assessment and it has to be answered in every report rather than hoped past.

Therefore every report states: that the assessment was conducted by video; the tier assigned and why; whether clearance was sought and what it said; what was directly observed; what could not be observed and why; who else was present; and any stopping rule applied.

A video assessment that does not distinguish observation from report is indefensible.

10Adverse events

Definition. Any deterioration beyond an expected short-term flare: operationally, any deterioration not resolved by the 7-day contact; any injury; any fall; any syncope; any event requiring treatment or assistance not otherwise anticipated; any significant psychological distress; or any breach of section 7.3.

Immediate response:

• Stop, and provide appropriate immediate care within scope
• Direct the support person, where one is present, and stay on the call
• Escalate to emergency services where indicated, using the address confirmed at 9.1
• Do not end the call while the person is unwell and alone
• Notify the treating GP where appropriate, with consent

Recording. Every adverse event is recorded in full: what happened, where in the sequence, the tier assigned and what assigned it, whether clearance was held, what was done, and the outcome at each follow-up.

Review. Every adverse event and every near-miss triggers a review of the screening structure and this protocol. If the screening did not identify a risk that eventuated, the screening changes, and the change is recorded in the version history, so that the document shows its own learning rather than quietly improving.

11Records and privacy

• The audit risk list, the interview record, the consent form, any clearance correspondence, the assessment record, every follow-up contact and any adverse event record are retained together as the clinical record
• Retention follows the applicable health records legislation in the person's State or Territory
• The person is told, before consenting, what is recorded, who it will be disclosed to, and that the report is prepared for use in an NDIS matter
• Contact with the treating doctor occurs only with the person's written consent
• Sessions are not recorded unless the person specifically requests it and consents in writing; where a session is recorded, the recording forms part of the clinical record
• The person may request a copy of the record

12Independence and scope

Simon does not treat anyone he assesses or reports for. Where the file shows that physical therapy is the missing element, the report says so and names what is needed. It does not offer it. This removes the pecuniary interest that a Tribunal can otherwise identify in a report recommending supports the author would provide.

Scope. The sequenced assessment is a physiotherapy assessment. It does not extend to psychiatric assessment, neuropsychological testing, or specialist medical opinion. Where the file needs one, the report says which and why.

The expert's duty. Although the Administrative Review Tribunal is not a court and the Harmonised Expert Witness Code of Conduct does not formally bind reports prepared for it, this practice adopts it voluntarily. The duty is to the decision-maker, not to the person paying for the report, and every report says so on its face.

The practical consequence is stated in the consent form: a report may conclude that the evidence does not support the person's application. That conclusion is delivered, and the fee is not contingent on it.

13Review

This protocol is reviewed:

• After any adverse event
• After any near-miss
• After any breach of section 7.3
• Annually, on the anniversary of version 1.0
• When any standard in section 2 is updated
• When Australian ME/CFS clinical guidance is issued or revised

Each version is dated. Superseded versions are retained and available on request.

A note on why this is worth doing properly

The sequenced assessment is a new way of producing this evidence. That is precisely why the governance has to be right. A novel protocol carries the risk of being the first person to cause a foreseeable harm doing something new, and "the Tribunal wanted better evidence" is not a defence to a client injury.

It is also, separately, the strongest answer available to a sceptical reader. The most persuasive thing in this document is not that the assessment is careful. It is section 6.3: the fact that for a large part of this caseload, somebody else has to say yes first.