Physical Therapy Documentation Guidelines OT & PT Services The American Physical Therapy Association (APTA) establishes professional standards of practice and documentation guidelines for the physical therapy profession. State regulatory boards, such as the Iowa PT-OT Licensure Board, also establish rules for the practice of physical therapy in the state of Iowa. In addition, physical therapists practicing in the educational setting have to meet documentation requirements of the Individuals with Disability Education Act (IDEA) and, in Iowa, the Area Education Agency. The purpose of this document is to merge documentation guidelines and requirements while utilizing a problem-solving approach to services. Pre-Assessment Level II Problem Solving Document Document Contact Child's identification information Concern Plan Follow-up contact Forms Functional Screening Tool for PT PT Service Record Pre-Assessment Level III Problem Solving, in conjunction with the educational team Document Problem analysis Intervention plans Decision-making plans All contacts Forms AEA Intervention Plan Or Job #1 Chart Problem Analysis Worksheet AEA Intervention Summary PT Service Record Full and Individual Evaluation, in conjunction with the educational team Level IV Summarize Data collected during intervention Discuss additional assessment data as appropriate APTA State pertinent diagnosis Review medical history Identify functional limitations Make a PT diagnosis Set goals Develop treatment plan Recommendation for PT services Forms Physical Therapy Evaluation Open Evaluation Early Childhood Team Report Other formats are acceptable IEP or IFSP Development, in conjunction with the educational team Refer to Heartland AEA Program Manual for Special Education Forms AEA IEP AEA IFSP Contacts Document Conversations Letters Telephone calls Meetings Student services Cancellations & reason Sign your entries Form PT Service Record Progress Report At least once a year, annual review or end of year Summarize intervention List significant changes in health or educational status Discuss ongoing service needs Throughout the year Communicate with other health care or educational providers Form Physical Therapy Progress Report Parent Progress Report, in conjunction with the educational team Document Student progress related to IEP goals Send on schedule established by local school district, coordinated with progress report schedule used in general education Forms Graphs IEP page with updated information IEP Progress Report Local school format Three Year Reevaluation, in conjunction with the educational team Review, as needed Functional mobility Positioning Forms Reevaluation/Case Review Physical Therapy Progress Report Discharge or Discontinuation of Services, in conjunction with the educational team Summarize Interventions Outcomes State Rationale for discontinuation Provide recommendations when appropriate Form Physical Therapy Progress Report School Suggestions or Home Program Ideas Document Training Suggestions Progress Copies to Therapist's file School Parent Form Individual Program Activities Transition Plan, in conjunction with the educational team Summarize Present level of performance Student needs List Adaptations Modifications Services needed Forms AEA Transition Plan Physical Therapy Progress Report Updated 3-25-00

http://www.aea11.k12.ia.us/otpt/ Email: agarrett@aea11.k12.ia.us