Documentation


 * 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).

b. Reevaluation Report || b. Service Contacts/Notes c. Progress Reports d. Transition Plan/Annual Summary Report ||
 * Box 1. Common Types of Occupational and Physical Therapy Reports**
 * **Process Areas** || **Type of Report** ||
 * I. Evaluation (see Assessment page) || a. Evaluation/Screening Report
 * II. Intervention (this pages focus) || a. Intervention Plan
 * III. Outcomes (see Dismissal page) || a. Discontinuation Report ||

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.
 * Effective Documentation AOTA Q&A with Cathy Brennan July 2014 **

(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.
 * ECPTOTE Adopted OT Rules - Effective January 9, 2012 **
 * [|§372.1 Provision of Services] **
 * (f) Documentation**

**A. Intervention Plans/Plans of Care** (relating to IEPs)
[|§346.1, Educational Settings]
 * Note: Adopted Rule Amendment January 2012**

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.

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.
 * PT: How often do I need to document treatment? **

(2) The licensee providing occupational therapy services must document for EACH intervention session...
 * OT: How often do I need to document treatment? **

**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.


 * Staffing/Consultation/Coaching**

**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)**

[[file:SessionNotesOT.doc]]


@https://docs.google.com/a/esc13.net/forms/d/1c7THhJ4eboAKnC5k6HnJMONbuz8-FULr9yg-QQvhbKU/viewform
 * 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)**