1. Documentation in School-Based Practice
OT Documentation Modules
Sandra Rogers, PhD, OTR/L

2. IDEA IDEA = Individuals with Disabilities Education Act (IDEA)
Under IDEA there are 3 types of documents:
Notice & consent forms
IFSP
IEP
Part B = sets forth requirements for States and local educational agencies (school districts) in providing special education and related services to children with disabilities, ages 3 through 21.
Part C = sets forth requirements for birth through 2 years of age (IFSP)
Response to intervention happens BEFORE a student is referred for services.
Parents are intended to see all documentation.
PARENTS AND SCHOOL PERSONNEL MUST WORK TOGETHER TO DEVELOP AN IEP
Part B of the Individuals with Disabilities Education Act (IDEA) sets forth requirements for States and local educational agencies (school districts) in providing special education and
related services to children with disabilities, ages 3 through 21. Part B emphasizes the importance of including parents in decisions regarding the education of their children. Before
a school district proposes or refuses to take action regarding the educational program of a child with a disability, the district must provide a “prior written notice” to the parents. The
district must also, at specified times, provide parents with a “procedural safeguards notice” which explains their rights under Part B of the IDEA. Further, parents and school personnel
must work together to develop an individualized education program (IEP) for each child which sets forth the services that the child will receive to meet his or her unique needs.

3. Documentation in school-based practice
Occupational therapists working in preschool or school environments gather data across multiple settings to facilitate participation and engagement within the student’s educational environment (e.g., classroom, playground, cafeteria, bathroom, hallways).
Documentation provides a critical chronological, legal record of occupational therapy services and student performance.
Review Chapters in Sames, K. (2015). Documenting OT practice. Boston, MA: Pearson
Online appendices at : Appendix C

4. School-based documentation & AOTA
AOTA establishes professional standards of practice and guidelines or the profession that provide occupational therapy practitioners with minimum standards that must be followed.
Referred to a AOTA’s guidelines for documentation of occupational therapy (2013)
IDEA has requirements for documentation at various points in the occupational therapy process in school practice.
Occupational therapy practitioners working in school environments must be knowledgeable of any conflicts between their state professional requirements and work requirements. Resolving these issues may require multiple conversations with state professional organizations and public agency administrators. One example might be the institution of a statewide template for teams to use for initial evaluations. The template did not contain information required by the state occupational therapy licensure practice regulations. After meeting with representatives from the state the template committee and Department of Education staff the decision was made to have a state wide occupational therapy evaluation report that reflected the requirements of the state occupational therapy licensure yet aligned with the headings of the statewide team template.

5. Three Fundamental Issues for documentation
Be objective: document what you saw in brief and complete sentences. Document all phone calls and correspondence. Document instructions and training as well as the person’s response. Never use derogatory or defensive language.
Be timely, legible, grammatically correct, and correctly signed: record data and time, when applicable. Delete use at least your first initial, full last name, credentials, and the date when you sign the document.
Provide tamper-free documentation: use ink, and make changes by drawing a single line through the error. Write your initials above or next to the error. Do not leave blank lines order large blank spaces on the document. Do not use correction fluid on permanent or official records.
There are three issues that can help avoid confusion in documentation.
Impressions are formed by reading and occupational therapy practitioners documentation.
Sloppy illegible or incomplete documentation may be perceived as poor judgment or quality.
The occupational therapy practitioners documentation maybe used in court.
The clients record as a permanent file that should be maintained in a legal and professional manner. Documentation should be well organized, provide an accurate and complete account of the services or communication that occurred, and follow the 15 fundamental elements of documentation.

6. 16 Fundamentals of Documentation
Background data (3)
General documentation (4)
Signatures (3)
Compliance (6)
All 15 are listed below in notes.
Background data (2)
Clients full name and case number on each page
Date
Client information related to the service (reports, service contacts, evaluation tools), DOB, gender, applicable medical, educational, or developmental diagnoses, precautions and contraindications.
General Documentation Issues (4)
Documentation should reflect professional clinical reasoning and expertise of an occupational therapy practitioner and the nature of occupational therapy services delivered in a safe and effective manner. The clients diagnoses or prognosis should not be the sole rationale for occupational therapy services
Identification of type of documentation (evaluation, progress report, note)
Acceptable terminology defined within the boundaries of the setting
Abbreviations usage as acceptable within the boundaries of the setting
Signatures (3)
Occupational therapy practitioners signature first name, last name, professional designation
Signature of the recorder directly after the documentation entry
Co-signature of an occupational therapist as appropriate for student
Compliance (6)
Compliance with all laws, regulations, payer, and employer requirements
All errors noted & signed
Adherence to professional standards of technology
Disposal of records within law or agency requirements
Compliance with confidentiality standards
Compliance with the agency or legal requirements of storage records

7. Referrals
Whenever and occupational therapist is asked to see you students here she should document the following items:
Who initiated the referral request, including their phone number and agency or district
Date date of the referral or request
What is wanted from the occupational therapy practitioner (i.e., purpose)

8. IEP Essential Content (per IDEA)
Present level of academic achievement and functional performance
Annual goals
Special education related services
Participation with nondisabled children
Participation in state and district-wide tests
Starting date and location of services
Transition services

9. IDEA OT processes requiring documentation for students
Evaluation
Determine eligibility
Specific OT evaluation
Re-evaluation
Outcomes/ goals
Determination of ongoing eligibility
Development of IEP goals or transition
Review of IEP goals
Intervention
Implementation & progress
Evaluation
Full and individual initial evaluation is completed as a team to determine whether a child is a child with a disability under IDEA and eligible for special education and related services
Specific occupational therapy evaluation of eligible students conducted to determine impact of functional, behavioral, and academic performance on health and participation and to identify need for occupational therapy services.
Reevaluation to review ongoing need for special education and related services; occupational therapy evaluation may result in continuation or discontinuation of services (every three years).
Outcomes
Determination of eligibility for special education by team; if eligible, student may receive related services as needed receive services as needed.
Development of IEP as a team to identify students functional, academic, and behavioral performance; prioritize needs; and establish student goals and services to meet them. Transition plans are included when appropriate.
IEP review to review student’s goals, and identify additions or deletions in services, based on current needs and goals.
Intervention
Implementation of IEP includes a description of how the students progress toward the goal will be measured; periodic reports on students progress are given to the family.
Professional recordkeeping and documentation are assumed.

10. Documentation Framework RIOT/ICEL
A framework to organize and document these data efficiently is the Review, Interview, Observe, and Test (RIOT)/Instruction, Curriculum, Environment, Learner (ICEL) Matrix.
This framework allows the user to organize four potential sources of information (RIOT) within key domains of the education setting (ICEL).
Instruction refers to how the content is taught, curriculum refers to what content is taught, environment refers to the context and conditions for learning, and learner refers to the student’s unique capacities and traits.
The learner is listed last on purpose; if the first three domains are “just right,” the learner will learn.
(Hosp, 2006, 2008; Wright, 2010)
Clark, F. (2015) Documenting in School-based practice. OT Practice 20(15).

11. ICEL matrix Instruction Curriculum Environment Learner
Instruction refers to how the content is taught, curriculum refers to what content is taught, environment where first to the contacts and conditions for learning, and the learner refers to the students unique capacities and traits.
Examples of how the content is taught refers to regular education or in a special classroom for example regular education kindergarten.
Curriculum refers to any particular curriculum that is used to convey the information for example a hand writing curriculum like handwriting without tears.
Environment of the classroom refers to things like how many students are in the classroom, classroom size, and desks or tables, size of the chairs, or how with the teacher has the desks arranged.
Learner refers to any individual characteristics about this student.

12. RIOT Review Observe Interview Test
The riot matrix shares many of the same ideas as the occupational therapy practice framework including context/environments client factors, performance skills, and performance patterns (learner) and occupations and activities.
Occupational therapist uses data from these areas to determine the need for services as well as the effectiveness of services.
Quantitative data should be gathered for the purpose of establishing a baseline and monitoring the students program.
When using the matrix, data may be entered in any order, but avoid leaving empty boxes.
Review
A complete and thorough record review provides information about the history and nature of the concern. Data, such as the number of days the students miss school, scores on State in previous assessments, Office disciplinary referrals, report cards, portfolios, and medical and educational history, can be used in decision-making. The purpose of reviewing these data is to determine support or barriers to the students current participation/performance into gather baseline performance data.
Interview
Interview sources to gather specific or qualitative and quantitative data that will allow for identifying supports and barriers to occupational performance and for measuring progress. Interview questions may be structured or informal and are typically open ended. Qualitative data are often obtained during interviews and can be used to identify the strengths and needs within the ICEL domains. Cross reference information provided in the interviews. Quantitative data may also be obtained during the interview for example Number of times a student has not handed in homework compared to the class average. Ask questions about educational and medical and developmental history motivation and current academic and social performance.
Observation
Information gained from observations can lead to the educational teams better understanding of the cause of the students academic nonacademic or behavioral problems. Observations can also assist in comparing the students performance with that of his or her peers. Structured observation should be planned carefully to identify the behavior and observable terms and within the typical context for observation the type of measurement should be based on the type of performance. Direct observations should occur in the students typical classroom environment within the natural routine. Use the four main components of IC EL to focus on the students response to the teachers instructional strategies, the students ability to work through curricular exercises, the impact of the physical and social aspects of the environment on the students learning and participation, and the student’s unique characteristics. Occupational therapist should select or devise quantitative methods for capturing the students performance within certain environments. Three examples of measurements by an occupational therapist may include 1) interval recording data focusing on on task behavior for a student was suspected attentional problems, 2) duration data using the number of seconds or minutes students completes an activity, 3) frequency data focusing on recording or counting the frequency
Test
Performance tests and tools provide the team with information about the students performance in schools. Occupational therapist may use the results from tests, classroom probes, or assessments normed for the district for evaluation, progress monitoring, or intervention planning.

13. RIOT/ICEL Worksheet
You can see from this may tracks that it shares the same ideas as the occupational therapy practice framework. It includes environments (context/environment), the learner (client factors, performance skills, and performance patterns) and occupations and activities. When using the matrix data may be entered in any order but avoid leaving empty boxes. When data is applicable to more than one section place it in only one box.

14. IEP Forms on the Web Find them at the state DOE page
Special Education Publications
Special Education
Dept. of Education Oregon
Download the form and review it

15. Documentation that Works
Documentation for ICF, AOTA, OTPF, MOP/FOR & ASD, ADHD, CP, ID, TBI within schools
In other words how does documentation align with MOP/FOR, AOTA/ICF, and Conditions, by setting.
Alignment of MOP for the facility/setting, condition, and documentation yet meet the state licensure and AOTA professional standards all need to take place.

16. Example of MOP Alignment with Documentation
MOP/FOR & Assessments
Key Concepts
Reflection in Documentation/Conditions
EoHP
The interrelationship of person and context determines which tasks fall within the person's performance range.
Assessments need to be done within the context (PEDI-CAT & SFA)
Physical qualities, cultural qualities, effects of relationships on performance, life roles, skills and abilities.
Ecology is the interaction between a person and contexts (environment).
The person, context and task performance interact and affect one another. Considers the effect of context. Context is described as a lens from which persons view their world.
Performance is improved by establishing/restoring the person’s skills or abilities, altering or adapting the context or the task to support performance in context, preventing occupational barriers, or creating enriching occupational performance.
Evaluation reports look not only at the person but also at contexts and tasks and the person-context match.
Progress reports describe what interventions have been tried and their results
Goals reflect the person’s participation in occupations and performance in context.
This model would work for any condition.
Fits well with OTPF
Top Down model
Could reflect ICF
Example of MOP Alignment with Documentation
This table is intended to be unfinished. Review Chapter 5 in in Sames, K. (2015). Documenting OT practice. Boston, MA: Pearson
Add MOHO, CMOP & CO-OP!
Relationship between OTPF & Models & Documentation
Top Down & Bottom UP
How do you document to show that you are using a top-down model?