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


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.




B. Service Contact Notes


Medicaid contact notes and billing logs (Nic, confirm which of these are most current)





progress monitoring- data sheets,

Training to staff

Letters to parents