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 Guidelines- American Occupational Therapy Association

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
Process Areas
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
(f) Documentation
(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):

Consultation Form

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

Can Student Access Instruction- AISD Rubric

B. Service Contact Notes

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

Letters to Parents

Letters to Physicians Re: Feeding Plan Approval (could also be for splints, etc)