Documentation in Schools Flashcards
The timeline for documentation
The Referral
The Evaluation
Parental Consent
Prescription
Annual Goals
Daily Notes
Progress Monitoring
ESY recommendation (if appropriate)
Annual Review/ Re-Evaluation
Discharge (when appropriate)
For direct services we need a
prescription
We need documentation to support ESY, what is ESY?
no idea
Who is on the interprofessional team?
Parents/Caregiver
Administration
Teachers
Special Education
Consultant Teacher
Psychologist
Social Work
School Nurse
Related Services:
OT
PT
SLP
Music Therapy
Teacher of the Visually Impaired
Orientation and Mobility
Teacher of the Deaf
When do we want the child involved in the interprofessional team?
ASAP. Legislation says 16 but we can do that earlier if they are ready for it.
Referral for CSE services may come through ____________ or ____________ and ____________
Rti or other early intervening services
Referral can be made from anyone involved (parent, teacher, therapist).
you are not suppossed to treat a child without a ________
What is the loophole
script
MTSS - you don’t have to bill for that but you could get the script later and then back bill.
INTERPRETATION OF EVALUATION
Make determination of strengths and needs
create IEP present level of performance (PLEP)
recommend a service delivery model appropriate for the student
create goals and objectives when appropriate
What if the parent disagrees with the recommendation of level of service?
The parent can get an independent evaluation
procedural safeguards - if you cant come to an agreement - due process and mediation.
you are still a good therapist.
Who do we use objectives for outside of preschool -
kids who can’t take the exams.
Measurable goals - Defining the Student’s Needs
Writing the goal
– Description of observable learner performance or behavior
–List any conditions or equipment needed
–Measurable criteria that specifies the level that is acceptable for “mastery”
Different types of service delivery
Direct Service Delivery
Consultation
Supports on behalf of the student
MTSS/RtI
Daily notes requirements
Every encounter must be documented
Contemporaneous records (within 24 hours)
Documentation Guidelines
- Objective
- Legible and grammatically correct
- Timely (Contemporaneous)
- Signed and dated
- Completed in ink (usually blue) or electronically
- Corrected appropriately
Session Note
Describes the information to support data collection
- Include:
- Preparation activities
- Intervention strategies (using pencil gripper, with visual model etc.)
- Any informational data on the student’s performance (observed to utilize non dominant hand effectively during cutting)
Progress towards goals
- Any cueing, modification or assistance the student needed (what you did as the therapist!)
- Plan for service
Supervision
Defined as a process that fosters growth and development; ensures appropriate use of training; and encourage creativity and innovation through providing guidance, support, encouragement and respect- all working toward a defined goal.
Supervision requirements
Medicaid guidelines- “Under the direction of”
OTR must see student at beginning and periodically during treatment
Familiar with treatment plan
Continued involvement, periodically reviews
Assumes professional responsibility
Time directly supervising
Documentation supporting supervision of services
NYS guidelines of supervision of OTAs
Written supervision plan
-Level and type based on ability level and experience
Participates on a regular basis
Responsible for determining need for continuing, modifying or discontinuing services
Available for OTA consultation in a timely manner
May only supervise no more than 5 OTAs or its FTE.
Documenting IEP goals
Data Collection
Goal Attainment Scaling
Monitor progress
Individualized, criterion-referenced approach
Progress monitoring
Uses student performance data to evaluate the effectiveness of instruction and intervention.
Process:
Starts with identifying a baseline
Create a measurable goal
Track data on student performance (measurable)
how to track progress
Tracking data to show change in performance
Checklists
Data charts
Completion of %
Observable/measurable behavior
Trials
Goal Attainment Scaling
Rubrics
Goal Attainment scaling
”Systematic method of describing clients’ current and progressive performance”
Used in goal setting, measuring progress toward intervention outcomes and measuring research.
Sensitive to individual outcomes
Evaluates change in stated participation challenges
Good strategy for measuring progress on weekly basis
Criteria for Writing Goals in GAS Format
Six Basic Requirements:
Relevant
Understandable
Measurable
Behavioural
Attainable
Time Frame
Steps for creating GAS Scales
- Identify overall goal/outcomes
- Identify specific problem areas
- Specify behaviors or events that would indicate progress (operationalize terms)
- Determine how data will be collected (who, what, where, when)
- Select expected level of performance
- Identify continuum of outcomes (most to least favorable)
- Review GAS to identify overlaps and gaps
- Determine child’s current status and when evaluations are needed to document progress
Through IDEA Legislation child has to have the opportunity to have
- extended school year.
- services have to be provided in accordance to IEP
- at no cost to parents
most common used extended school year
substantial regression
What is substantial regression?
would be indicated by a student’s inability to maintain developmental levels due to a loss of skill, set of skill competencies or knowledge during the months of July and August.
What is absolutely necessary for substantial regression?
Track data on how long it took to recoup the skill to the level prior to a break in services (December break)
Track what they lost during breaks - how long does it take to recoop the skill.
It has to be double the amount of time to recoop in order to justify services.
summer is intended to maintain skills not
regress
critical skill
if the child is at a critical skill development point where summer break would not allow them to progress you can ask for critical skill development reasons to get extended school year.
Annual Review-
IEP must be reviewed by the IEP team at least once a year.
Long term goal is for students with disabilities to leave high school prepared to work, attend higher education and live independently.
this is a consideration for
annual review
during the annual review we ask does the child still need services or should it be discontinued
true
Re-evaluation must
occur at least every 3 years to determine if the child continues to meet the criteria as a “child with a disability” as defined by IDEA.
when to discharge
- Services are no longer educationally relevant
- Goal has met and no other goals are appropriate
- Skill and expertise of OT are no longer required
- Therapy is contraindicated
- Parents decline ongoing goals or service
