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About Related Services
RtI- Response to Intervention
Determining Needs & Services
Physician Referrals for School Therapy
Online Training Opportunities
Self-Contained Structured Classrooms- Life Skills
School System FAQ
TEAs Guidance for RS
Add "All Pages"
Documenting Frequency and Duration for Special Education and Related Services (TEA Special Ed Monitoring Guidance Sept 2014)
What does IDEA, TEA, licensure and medicaid tell us to document? How long to keep records? Legally defensible records?
Documentation Retention _Legally Defensible Documentation for SchoolESC13_3.23.12.docx
Documentation Guidelines- American Occupational Therapy Association
OT documentation per AOTA.pdf
Documentation should always record the professional’s activity in the areas of evaluation, intervention, and outcomes (AOTA, 2002, 2007).
Box 1. Common Types of Occupational and Physical Therapy Reports
Type of Report
I. Evaluation (see Assessment page)
a. Evaluation/Screening Report
b. Reevaluation Report
II. Intervention (this pages focus)
a. Intervention Plan
b. Service Contacts/Notes
c. Progress Reports
d. Transition Plan/Annual Summary Report
III. Outcomes (see Dismissal page)
a. Discontinuation Report
Effective Documentation AOTA Q&A with Cathy Brennan July 2014
AOTA: What are your do’s and don’ts for successful documentation? Brennan: One “do” is to be sure that your
evaluation includes a baseline of functional performance. Without a baseline, change cannot be measured.
One “don’t” is using the term “age appropriate” as an outcome goal with developmentally delayed children who will probably never achieve this but will develop functional skills.
ECPTOTE Adopted OT Rules - Effective January 9, 2012
§372.1 Provision of Services
(1) The patient's/
client's records include
the medical referral, if required;
and the plan of care. The plan of care includes the initial examination and
evaluation; the goals and any updates or change of the goals; the
documentation of each intervention session by the OT or OTA providing
the service; progress notes, any re-evaluations, if required; any written
communication and the discharge documentation.
A. Intervention Plans/Plans of Care
(relating to IEPs)
Note: Adopted Rule Amendment January 2012
§346.1, Educational Settings
The amendment eliminates the specific requirement that a PT review the Individual Education Program
every 30 days and require PTs and PTAs to follow the rules in Chapter 322 of this title, regarding
reevaluation, documentation and supervision if a PT or PTA is providing "hands-on" physical therapy
treatment in the school setting.
PT: How often do I need to document treatment?
The Board requires documentation of EACH treatment session; in other words, there should be an entry for every visit or encounter between the patient and the PT or PTA.
OT: How often do I need to document treatment?
(2) The licensee providing occupational therapy services must document for EACH intervention session...
Intervention Plans of Care Examples
- (I like some of the updated wording on the OT POC using OT Framework Terminology!) (some from out-of-state):
Intervention Plan PT_Leander.doc
OT Intervention Plan_Leander.doc
OT Intervention Plan 11-12_DripSprings_KM.doc
Parents have a difficult time trusting that when services move to a consultation and collaborative model their child is getting quality services. There is a form on pages 144-146 of the book-each ESC 13 district should have -
Collaborating for Student Success: A Guide for School-Based Occupational Therapy
that we might consider using rather than a narrative note. Its format is structured, has built-in accountability and is user-friendly to teachers, parents, OTAs & PTAs, etc.
Classroom Observation Forms
Ecological Inventory Form_Downing_IW 2010_exampleELA.docx
Can Student Access Instruction- AISD Rubric
rubric- AGC- classroom obs_AISD.pdf
B. Service Contact Notes
OT Progress Notes_RRISD.pdf
Medicaid contact notes and billing logs (Nic, confirm which of these are most current)
Go Digital- Use a Google Form for easy documenting, graphs for student progress, etc
Progress Monitoring- Data Sheets
Evidence of Staff/Parent Training
STAFF TRAINING FORM.doc
Letters to Parents
Parental Consent for Temporary Mounting System 2007.doc
Letters to Physicians Re: Feeding Plan Approval (could also be for splints, etc)
help on how to format text
Turn off "Getting Started"