Editor's note: This text-based course is a transcript of the webinar, Documentation In School-Based Occupational Therapy, presented by Krupa Kuruvilla, MA, OTR/L.
*Please also use the handout with this text course to supplement the material.
Learning Outcomes
- As a result of this course, participants will be able to identify the missing components in OT goals to make them structured, measurable, and educationally relevant.
- As a result of this course, participants will be able to list the contents of the different types of documentation in occupational therapy in the school setting and recognize the elements that need to be included and do not.
- As a result of this course, participants will be able to compare and contrast the types of documentation in the school-based setting, common mistakes, and how to correct them.
Introduction
I’m Krupa, a pediatric occupational therapist and founder and owner of TotalReport. With experience across six school districts in the Bay Area of California, I’ve developed a deep understanding of occupational therapy practitioners' (OTPs) unique challenges, especially regarding documentation. Through this course, I aim to simplify the documentation process in school-based OT, transforming it from a cumbersome task into a manageable and rewarding part of your practice.
The Purpose of This Course
This course is designed to help occupational therapy practitioners streamline their documentation process. We will focus on decreasing the time spent on documentation while ensuring it is thorough, concise, and effective. You'll learn what to include, what to leave out, and how to write documentation that communicates your services clearly to a range of readers, from other healthcare providers to teachers and parents.
We’ll cover the purpose of documentation, the types and contents of required documents, best practices for goal writing, documentation for sensory integration (SI) interventions, and proper discharge procedures. By the end of this course, documentation should feel like a straightforward task rather than a burden.
Why Documentation Matters
Documentation is vital to providing professional services to students. As an OTP in a school setting, your documentation must support the specific skilled care you provide and show its therapeutic and educational necessity. Documentation is not just about recording what was done; it’s about justifying why and how it aligns with the student’s functional and educational goals.
The mantra I advocate is, "Write better, not more." It’s common for inexperienced practitioners to overload their notes with details in the hope of being thorough. However, this often obscures the key information. Your documentation should be succinct yet comprehensive enough to reflect the nature of the services provided, the clinical reasoning behind them, and the student’s response to the interventions.
Types of Documentation in School-Based OT
Various types of documentation are essential in school settings for tracking and supporting student progress. These typically include screening reports, evaluation reports, re-evaluation reports, intervention plans or plans of care, daily treatment notes, progress reports, discharge reports, and transition plans.
1. Screening Reports
A screening report is completed when an occupational therapy referral is made, often before a comprehensive evaluation. It briefly describes the student's abilities and determines whether a full evaluation is needed.
- Contents of a Screening Report:
- Referral Information: Date and source of referral, services requested, and the reason for the referral.
- Student Background Information: Student’s name, date of birth, family history, medical history, health status, relevant diagnoses, and any precautions or contraindications (especially for medically fragile students).
- Description of the Student's Abilities: Areas where the student is successful, areas where they face challenges, and the school contexts and environments that support or hinder occupational performance.
- Record Review: Review previous and current IEPs, therapy reports, and relevant classwork samples.
- Clinical Observations: Observations conducted in various school settings such as the classroom, lunchroom, playground, etc.
- Informal Interviews:** Insights from teachers and parents.
- Summary and Recommendations: Professional judgment on needing a full OT evaluation based on screening results.
2. Evaluation Reports
An OT evaluation report is created after a comprehensive assessment is conducted following the pre-referral process. It documents all findings from the evaluation.
- Contents of an Evaluation Report:
- Referral Information: Details of the initial referral and results from the screening, if applicable.
- Student Background Information and Occupational Profile: Detailed information about the student’s areas of success and challenge, supported by resources like those found on the AOTA website.
- Assessments Used and Results: Types of assessments (structured, non-structured, standardized, non-standardized), interviews, record reviews, observations, and a detailed account of the results.
- Analysis of Occupational Performance: Identification of factors that support or hinder the student’s performance and participation.
- Summary and Analysis: Identify targeted areas of need that should be addressed.
- Recommendations: Professional judgment regarding the need for OT services, including service frequency, duration, and specific goals.
3. Re-evaluation Reports
A re-evaluation report is completed periodically to reassess the student’s progress and needs. It helps determine if the current intervention plan is still appropriate or if adjustments are necessary.
- Contents of a Re-evaluation Report:
- Updated Background Information: Changes in the student’s medical, educational, or developmental status.
- Review of Previous Interventions: Summary of the interventions provided and progress made since the last evaluation.
- Current Assessments and Observations: Updated assessments, observations, and their results.
- Analysis of Progress: Comparison of current performance with previous reports.
- Recommendations: Continuation, modification, or discontinuation of services based on the re-evaluation findings.
4. Intervention Plans (or Plans of Care)
An intervention plan outlines the specific OT services the student will receive, including goals and strategies to address identified needs.
- Contents of an Intervention Plan:
- Student’s Needs: Summary of the areas identified during evaluation or re-evaluation.
- Goals: Specific, measurable, attainable, relevant, and time-bound (SMART) goals for the student.
- Intervention Strategies: Detailed description of the therapeutic approaches and activities.
- Service Delivery: Frequency, duration, and location of OT services.
- Collaboration: Plan to work with teachers, parents, and other professionals.
5. Daily Treatment Notes
Daily treatment notes document each therapy session, providing a record of what was done and the student’s response.
- Contents of Daily Treatment Notes:
- Date and Time of Session: Documentation of when the session took place.
- Activities Conducted: Brief description of the therapeutic activities performed.
- Student’s Response: How the student responded to the activities, including any progress or challenges.
- Modifications: Any changes made during the session to accommodate the student’s needs.
- Next Steps: Plan for future sessions based on the student’s response.
6. Progress Reports
Progress reports are typically written regularly to summarize students' progress toward their goals.
- Contents of a Progress Report:
- Overview of Goals: Restatement of the goals set in the intervention plan.
- Summary of Progress: Detailed account of the student’s progress toward each goal.
- Challenges: Identification of any barriers or challenges that have impacted progress.
- Updated Recommendations: Adjustments to goals or intervention strategies based on progress.
7. Discharge Reports
A discharge report is created when the student no longer requires OT services, either because they have met their goals or for other reasons.
- Contents of a Discharge Report:
- Summary of Services Provided: Overview of the OT services the student received.
- Goals Achieved: Detailed account of the goals that were met.
- Reason for Discharge: Explanation of why services are being discontinued.
- Recommendations: Suggestions for maintaining progress after discharge, including strategies for teachers and parents.
8. Transition Plans
A transition plan is developed when a student moves from one educational setting to another, such as from elementary to middle school.
- Contents of a Transition Plan:
- Overview of Current Status: Summary of the student’s abilities and needs.
- Preparation for Transition: Specific strategies and goals to prepare the student for the new environment.
- Collaboration: Plan for coordination between current and future teachers, therapists, and parents.
- Recommendations: Suggestions for continued OT support in the new setting, if needed.
Common Documentation Mistakes
1. Ineffective History Taking:
One of the most common mistakes in writing evaluation reports is skipping effective history taking. When gathering a student's medical or therapy history, it’s crucial to include all relevant past therapies and co-morbidities, even if they aren't the primary reason for the OT referral. Co-morbidities can significantly affect the student's progress toward achieving outcomes. For example, a student referred for developmental delay might also have sensory integration concerns that impact their school performance. Failing to address these co-morbidities in your report can lead to incomplete treatment planning. In addition to identifying these co-morbidities, you should also explain how they could impact the plan of care or treatment plan. For instance, you might state, “In addition to fine motor delays, the student exhibits significant proprioceptive seeking behaviors that affect her ability to perform tasks like holding a pencil or crayon, leading to difficulties with handwriting, coloring, and other visual motor tasks.”
2. Not Addressing Cognitive Impact on Progress:
Another common mistake is failing to address how cognitive deficits may impact the student’s progress. If a student has a cognitive deficit that affects their ability to achieve OT goals, this should be mentioned in the report. For example, rather than simply stating that “the student is unable to perform a three-step motor task,” you should explain how the cognitive deficit affects their performance, such as: “The diagnosis of intellectual disability significantly impacts the student's ability to sequence steps correctly, leading to difficulty with motor planning tasks in the classroom.”
3. Failure to Interpret Standardized Test Scores:
It’s not enough to list the scores from standardized tests; these scores must be interpreted meaningfully by readers who may not have an OT background. Simply stating that “the student's fine manual control composite is 20, and her proficiency is in the fourth percentile” does not convey the impact of these scores on the student's daily functioning. Instead, you should explain the implications: “Based on the test results and performance, the student's primary challenges involve fine motor precision and integration. These difficulties may result in problems with tasks such as coloring, solving puzzles, and handwriting in the classroom.”
4. Omitting Baseline Functional Performance:
Developing a functional performance baseline is essential for setting goals and measuring progress. Without a clear baseline, it is impossible to determine whether the student has progressed. The baseline provides the starting point for treatment and is crucial for evaluating student status changes over time.
5. Inadequate Differentiation Between Skilled and Non-Skilled Services:
In your documentation, it’s important to differentiate between skilled OT services and non-skilled services. Your evaluation report should clearly articulate what skilled interventions are required to help the student achieve their goals and why they cannot be carried out by someone without specialized training.
Common Mistakes in Writing Re-evaluation Reports
A re-evaluation report includes everything an initial evaluation report does but with a focus on new findings and any necessary changes to the OT services, intervention plan, goals, frequency, and duration of services.
Reasons for a Re-evaluation:
- Discovery of new findings that require a different treatment plan or new goals.
- Significant changes in the student’s progress or medical status.
- Long absences from therapy require an update to the goals and treatment plan.
- Lack of response to the current therapy plan, necessitating adjustments.
Common Mistakes in Writing Intervention Plans (or Plans of Care)
1. Not Making the Activities Student-Centered and Measurable:
Intervention plans should focus on the student's achievement, not just what the therapist plans to do. The goals should be measurable, meaningful, occupation-based, and educationally relevant.
2. Incomplete or Inadequate Documentation:
Statements like “the student continues to participate actively in therapy sessions” do not provide useful information about the student’s progress. Instead, your documentation should answer questions like: What was the student's status? What gains have been made since the last session? What new responses to treatment have been observed, if any?
3. Changing Frequency or Duration Without Explanation:
Any changes to the frequency or duration of OT services should be justified. For example, if the frequency of OT services is reduced from two sessions per week to one, you should document the reason, such as: “The student is making good progress, and the reduction in frequency will allow for evaluation of whether success can be maintained at a reduced frequency.”
4. Failing to Document Changes in Goals:
If a student’s status changes from the performance baseline, updating or adding new goals and communicating them in your notes is important.
5. Lack of Proof of Supervision:
If you supervise a COTA or an OT student, you must include a statement from the supervising OT indicating that the plan has been reviewed and approved. This ensures that all activities are conducted under proper supervision.
Common Mistakes in Re-evaluation and Discharge Reports
In schools, a comprehensive re-evaluation, known as a triennial report, is conducted every three years for all students receiving OT services unless a determination to discharge the student is made before this date. A re-evaluation report should include all the elements of the initial evaluation report, focusing on re-evaluation results. It should update the recommendations regarding OT services, intervention plans, goals, frequency, and duration and include referrals to other professionals if needed.
If a student is discharged from OT services, a formal re-evaluation or discharge report is required to document the reasons for discharge, including progress made, goals achieved, and any follow-up recommendations.
Writing Effective Goals
Revising OT Goals for Clarity and Measurability: A Fun Exercise
Let’s engage in a practical exercise to examine common mistakes in goal writing and work together to make those goals more effective. I’ll walk you through the errors and explain how to break down and simplify goals for better clarity and measurability. By the end of this exercise, you’ll have a stronger grasp on creating goals that are easier to track and more reflective of student progress.
Mistake 1: Overly Complex Goals
One common mistake is writing too complex goals with too many components, making it difficult to measure and track progress effectively. For example, consider this goal:
Original Goal:
“Bobby will complete a variety of inset puzzles, interlocking puzzles, and mazes independently in four out of five trials with minimal assistance for increased visual motor and spatial relationship skills.”
This goal involves three tasks (inset puzzles, interlocking puzzles, and mazes) requiring separate measurements. Although these activities all work on visual motor skills, bundling them together makes it difficult to track progress effectively and overwhelms Bobby.
Revised Goal:
“Bobby will complete a set of three inset puzzles independently in four out of five trials with minimal assistance for increased visual motor and spatial relationship skills.”
By simplifying the goal to focus solely on inset puzzles, we create a clear and measurable target for Bobby. I always explain to the IEP team that this goal is just one aspect of Bobby’s visual motor skill development. He will still be working on other tasks, but we need a measurable way to assess his progress for documentation purposes.
Mistake 2: Including Too Many Tasks in One Goal
Another common pitfall is including too many distinct tasks within one goal. Let’s take a look at this example:
Original Goal:
“Brian will demonstrate the ability to independently write all uppercase and lowercase letters and numbers from 1 to 10 with accurate formation and orientation to the line with 80% accuracy as measured by the OT.”
This goal requires Brian to master both uppercase and lowercase letters and numbers, which is a lot to tackle in one objective. Measuring and tracking progress across so many tasks at once can become overwhelming.
Revised Goal:
“Brian will independently write uppercase and lowercase letters with accurate formation and orientation to the line with 80% accuracy.”
Focusing on just the letters breaks the task down into more manageable steps. This allows us to track Brian’s progress with greater accuracy and clarity. Once he achieves this goal, we can set a new goal for writing numbers.
Mistake 3: Vague or Non-Specific Goals
Sometimes, goals are too vague, lacking the detail needed to measure a student’s progress. For example:
Original Goal:
“Tina will improve her precision handling.”
This goal does not specify how Tina will improve her precision handling or the target activity, making it impossible to measure her success.
Revised Goal:
“Tina will string and unstring 10 large beads onto a firm lace three times with 20% verbal cues for increased precision handling as measured by the OT.”
This version specifies the task (stringing beads), the amount of assistance Tina can receive, and the number of repetitions needed to measure her progress. Now, her precision handling improvement can be tracked effectively.
Mistake 4: Lacking Specific Criteria for Assistance
It’s important to clearly define the level of assistance allowed within a goal. Often, goals fail to specify how much or what kind of assistance is permissible, leading to confusion when measuring progress. Consider the following:
Original Goal:
“Jenna will complete self-feeding for 90% of a meal for increased functional independence.”
This goal lacks information about what kind of assistance Jenna can receive, which is essential for understanding her progress.
Revised Goal:
“Jenna will complete self-feeding with 50% nonverbal cues for 90% of the meal for increased functional independence in four out of five trials.”
Here, we specify that Jenna is allowed 50% nonverbal cues. This clarity helps ensure that her progress can be consistently tracked across multiple trials.
Mistake 5: Not Defining the Context
Goals that lack context can be difficult to measure because they don’t provide enough information about where or under what conditions the task will be completed. For instance:
Original Goal:
“Mike will focus on a task in the classroom for 20 minutes with 80% accuracy.”
This goal doesn’t provide enough detail about what kind of task Mike will be working on or in what setting. Does he struggle with focus during specific tasks or at certain times of the day?
Revised Goal:
“Mike will focus on a tabletop task for 10 minutes during independent seat work, given no more than two verbal prompts, with 80% accuracy as measured by the OT.”
This revision specifies that the task will be a tabletop activity during independent seat work. It also defines the amount of assistance Mike is allowed, making it easier to measure his focus accurately.
Final Thoughts on Goal Writing
As you can see, we can transform vague or overly complex goals into clear, measurable objectives with just a little adjustment. This makes it easier to collect data and track student progress. Starting with well-written goals will always save time and make your work more manageable in the long run. By focusing on clarity, simplicity, and measurable outcomes, we can ensure that our goals are achievable for the student and useful for tracking their development.
Frameworks
Exploring Goal Writing Frameworks for Pediatric OT
When writing effective, measurable goals in pediatric occupational therapy, we rely on a few key frameworks to help us structure and streamline the process. These frameworks make goal-writing faster and ensure the goals are clear, actionable, and aligned with the student's needs. Let's delve into the three most commonly used frameworks: SMART, RUMBA, and COAST. Each one offers a slightly different approach but shares the same focus on clarity, measurability, and relevance to the student's therapy.
The SMART Framework
The SMART framework is perhaps the most widely known method for goal setting across many disciplines, including occupational therapy. SMART is an acronym for Specific, Measurable, Attainable, Relevant, and Timely. Here’s how each component contributes to writing better goals.
- Specific: The goal should target the student's specific area of need. Instead of vague statements like "improve motor skills," be precise: "increase pencil grip strength to support handwriting."
- Measurable: You must be able to measure progress toward the goal. For example, "Tina will complete five repetitions of stringing beads independently in four out of five trials." This allows you to track exactly when the goal is met.
- Attainable: The goal should be realistic and achievable for the student, given their current abilities. If a goal is too easy, it won’t challenge the student; if it’s too difficult, it may lead to frustration. For instance, asking a student with severe fine motor delays to write a full paragraph may not be attainable. Instead, start with "Tina will write her name with proper letter formation."
- Relevant: The goal should focus on skills that are meaningful to the student's daily life or educational needs. Is the goal addressing a function that will improve their participation in school or at home? For example, working on self-feeding for increased independence is highly relevant for many pediatric students.
- Timely: Set a timeframe within which the goal should be achieved. This creates a sense of urgency and helps prioritize therapy activities. For example, "Tina will complete the goal within six months." This ensures progress is tracked and adjustments can be made if necessary.
The RUMBA Framework
The RUMBA framework, from Willard & Spackman’s Occupational Therapy, offers another structured approach to goal setting. RUMBA stands for Relevant, Understandable, Measurable, Behavioral, and Achievable.
- Relevant: Like SMART, the goal must be meaningful and relevant to the student’s function. It should directly relate to the areas the student needs to improve in order to participate more fully in daily activities.
- Understandable: This component focuses on making the goal clear and understandable, not just to the therapist but also to the student, parents, and other team members. A goal everyone understands makes collaboration easier and ensures that the student and family fully engage in the therapeutic process.
- Measurable: Similar to SMART, the goal must include a way to measure progress. What specific criteria will indicate that the student has achieved the goal? For example, "Tina will be able to string five large beads without assistance in 80% of opportunities."
- Behavioral: The goal should describe a specific behavior that the student will perform. Instead of focusing on vague concepts like "improve attention," it’s better to write, "Tina will remain seated during circle time for five minutes with one verbal prompt."
- Achievable: The goal must be realistic given the student's abilities and available time. It should challenge the student without being unattainable. For example, setting a goal for a nonverbal student to independently engage in social conversation might not be achievable within the timeline. Instead, focus on small, achievable steps like "Tina will use a communication device to answer yes/no questions in four out of five trials."
The COAST Framework
The COAST framework is a goal-setting method tailored specifically to occupational therapy. COAST stands for Client, Occupation, Assistance Level, Specific Conditions, and Timeline.
- Client: The goal should clearly state what the client (or, in this case, the student) will do. For example, "Tina will improve fine motor skills."
- Occupation: Focus on the meaningful occupation or task for the student. For example, "Tina will use a tripod grasp to hold a pencil."
- Assistance Level: Specify the level of assistance the student will need to achieve the goal. Will the student perform the task independently or with some assistance, such as "with minimal verbal cues?"
- Specific Conditions: This refers to any specific conditions under which the student will perform the task, such as "during writing tasks at her desk."
- Timeline: As with the other frameworks, COAST goals should include a timeline within which the goal is expected to be achieved, such as "within three months."
By incorporating these elements, the COAST framework ensures that goals are student-centered, focused on meaningful activities, and include clear criteria for success.
Practical Example Using All Three Frameworks
Let’s say you are working with a student, Tina, who has difficulty with fine motor skills, particularly using a tripod grasp to hold a pencil. Here’s how each framework might help you structure a goal.
- SMART Goal Example: "Tina will use a tripod grasp to hold a pencil for 10 minutes during writing tasks with no more than two verbal prompts, achieving this 80% of the time within six months."
- RUMBA Goal Example: "Tina will use a tripod grasp to hold a pencil during writing tasks for at least 10 minutes with 80% accuracy. This goal is measurable, relevant to her academic needs, and achievable with consistent practice."
- COAST Goal Example: "Tina will hold a pencil using a tripod grasp (Occupation) for 10 minutes (Specific Conditions) with no more than two verbal prompts (Assistance Level) during writing tasks at her desk (Timeline: within six months)."
Each framework provides a structure to create specific, measurable goals tailored to the student’s needs. While the frameworks differ slightly in their focus, they all work toward the same goal: creating clear, actionable objectives that guide therapy and track student progress effectively.
Understanding Pediatric Assessments as a New Therapist
As a new therapist, I had numerous questions about how to write pediatric assessments effectively. One of the most common challenges I faced was understanding the differences between standardized and non-standardized assessments. I often needed guidance from a mentor or a more experienced colleague to navigate these areas.
Standardized Assessments
Standardized assessments are formal tools, often paper-and-pencil-based, but may include functional components. The term "standardized" refers to the fact that these assessments are designed to measure a student's abilities compared to other students of the same age or typically developing peers. This standardized approach allows us to objectively quantify a student's performance and identify areas of need.
Why Use Standardized Assessments?
We primarily use standardized assessments because they provide a structured and reliable way to evaluate students' abilities. By comparing the student's performance to established norms, these assessments help us understand how a student is functioning relative to their peers, which can guide intervention planning.
Occupational Therapy Evaluation
We’ve already discussed the essential components of an occupational therapy evaluation, such as establishing a baseline of the student's current status and using that as a guide for intervention planning. It’s important to include more than one assessment in your evaluation. Ideally, you should incorporate at least one assessment that addresses a sensory component and another that addresses a motor component. This comprehensive approach ensures you capture a full picture of the student's abilities and challenges.
Expanding Your Assessment Toolkit
As a school-based therapist, learning about new assessments and expanding your toolkit is always beneficial. Staying updated with current trends and incorporating new assessments into your practice can help you better meet the needs of your students. Here, I've included a list of some commonly used pediatric OT assessments that you might find useful.
Non-Standardized Assessments
A common question I encountered, especially when working with a moderate to severe population, was about the relevance of non-standardized assessments. I often wondered if a report without standardized assessments could still be considered strong and valid. The truth is that non-standardized assessments are sometimes necessary, particularly for certain populations or specific needs that may not be adequately captured by standardized tools.
Why Use Non-Standardized Assessments?
Non-standardized assessments offer flexibility and can be tailored to the unique needs of individual students. They allow for a more qualitative, descriptive evaluation of a student’s abilities, which can be particularly valuable when standardized tools are not appropriate or available. For instance, when working with students who have significant cognitive or physical disabilities, non-standardized assessments may provide the most accurate picture of their functional abilities.
Ensuring Validity in Non-Standardized Assessments
While non-standardized assessments may not provide the same type of normative data as standardized tools, ensuring they have strong internal validity and are grounded in evidence-based practices is crucial. By carefully selecting and using non-standardized assessments, you can produce meaningful and reliable reports, even if they don’t include standardized scores.
Frequently Asked Questions About Evaluation
When I first started as a pediatric occupational therapist, I had many questions about how to conduct evaluations effectively. Over time, I learned that thorough preparation and understanding available tools are key to successful assessments. Here are some other tips.
Preparing for the Evaluation
One of the first things I realized was the importance of being well-prepared before even stepping into the evaluation. Always, always start by thoroughly reading the student’s history. This gives you an idea of what standardized tests and equipment you might need and helps you understand the student’s background better. If you're not familiar with a particular diagnosis, it’s crucial to read up on it—understanding how it typically presents will guide your approach to the evaluation.
Having everything ready beforehand can save you a lot of time and stress. For example, have the student’s name and date of birth handy, and prepare an evaluation template. This ensures you won’t miss any important information. If you're using an assessment kit that’s new to you, practice with it ahead of time. You can run through it on your own or with a colleague who’s familiar with it. This practice will boost your confidence and ensure that you conduct the evaluation smoothly and accurately.
How Long Does It Take?
Another question that often came up was about the duration of evaluations. In a school setting, a typical pediatric assessment might take about one to two hours. However, this can vary depending on what’s required. Sometimes, you need to observe the student in different environments—such as the classroom, lunchroom, or playground—especially if they struggle in specific settings like PE or music class. These observations are crucial to getting a full picture of the student's abilities and challenges.
What If You Can’t Finish in One Session?
There were times when I couldn’t complete the entire evaluation in one session, and I quickly learned that this is not uncommon. Sometimes, the student might not be cooperative, or perhaps they’re absent. Occasionally, the assessment itself might be lengthy or new to you, leading to the need for an additional session. It’s generally possible to determine the need for OT services in one session, but don’t hesitate to schedule a follow-up if necessary. This ensures you gather all the information needed to set accurate goals and determine the appropriate frequency of services.
Choosing the Right Tests
A frequent question I had was about the number of standardized tests to use. The best practice is to use at least two standardized tests—one that addresses a motor component and another that covers a sensory component. Depending on the student’s needs, you might also include a visual perceptual assessment. One thing to remember is that it’s recommended not to repeat the same standardized test within a year. For example, if a student has been evaluated using the Bruininks-Oseretsky Test of Motor Proficiency (BOT-2) within the last six months, it’s better to choose a different test to avoid skewed results due to familiarity with the materials.
When Standardized Scores Aren’t Possible
I also learned that sometimes, particularly with students who have severe disabilities, standardized scores might not be obtainable. In these cases, don’t worry—clinical observations and interviews with parents and teachers become critical. These qualitative insights can be just as valuable as quantitative data, providing a clear picture of the student’s abilities and needs.
Setting Goals
Another important aspect is setting realistic and manageable goals. Every student and therapist is different, but I found that proposing two to four goals works well. This allows you to address multiple areas without spreading yourself too thin. Managing more than four goals can be challenging, especially when school therapy sessions are limited to once or twice a week.
When Treatment Isn’t Immediately Recommended
Interestingly, I also discovered that there are situations where OT treatment might not be recommended immediately, even if there seems to be a significant need. For example, I once worked with a three-year-old who had considerable sensory needs, but they also displayed challenging behaviors likely due to recent family changes, like the arrival of a new baby. In such cases, referring the student to a behavior analyst or registered behavior therapist might be more appropriate before proceeding with OT. This ensures that the underlying issues are addressed first, making the OT intervention more effective later.
The Importance of Collaboration
Through all of this, the most important lesson I learned was the value of collaboration with the interdisciplinary team. As a school-based OT, your role is crucial, but you are part of a larger team. Understanding the child's history, accurately interpreting your assessment findings, and applying sound clinical reasoning are all essential, but so is working closely with teachers, parents, and other professionals. A lot of learning happens on the job, and staying open to new ideas and approaches is key to providing the best possible care for your students.
Discharge Documentation
When it comes to discharge documentation for school-based occupational therapists, it's essential to approach the process with both positivity and sensitivity. Discharging a student from OT services is a milestone that should be celebrated, but it also requires careful communication with parents and caregivers to ensure they feel supported and understand the next steps. Here are some tips to make the discharge process smooth and effective:
Present Discharge as a Positive Milestone
When discussing discharge with parents, always frame it as a positive achievement. You might say, "Yay, Krupa has graduated from occupational therapy! She no longer needs services because she has made such great progress." This helps to reassure parents that the discharge is a sign of their child's success and growth.
However, be mindful that some parents might feel anxious about losing a service they perceive as crucial to their child's development. It is important to acknowledge these feelings and reassure them that their child is ready to move forward without OT support.
Provide Comprehensive Discharge Documentation
Your discharge report should be thorough, including standardized test results, observations, and a detailed summary of the child's functioning. This report will serve as a formal record of the child's progress and the rationale for discharge.
Offer Additional Resources
To ease the transition, provide parents with resources to support their child post-discharge. For example, if a student had proprioceptive or vestibular needs, you could recommend activities like gymnastics or dance classes that align with their interests and continue to support their sensory needs. These suggestions can be invaluable, as parents may not make these connections independently.
Suggest Home Program Activities
Empower parents and caregivers with home program activities that can be easily integrated into daily routines. Provide handouts with simple exercises that don't require specialized equipment, like using clothespins for fine motor strengthening. These activities ensure continued skill development and help bridge the gap after therapy ends.
Back Your Suggestions with Clinical Reasoning
When making recommendations in your discharge report, always include the clinical reasoning behind your suggestions. This adds credibility and helps parents understand why certain activities or resources benefit their child. For instance, explain how a specific class or home activity can support the continued development of skills targeted during therapy.
Educate on Community Integration
Encourage parents to involve their child in community activities that promote social and functional participation. Educate them on the importance of community integration and provide specific examples of activities or programs that would benefit their child. This helps parents feel more confident in supporting their child's continued development outside of school.
Maintain Open Communication
Discharge can feel like the end of a safety net for many parents, so maintaining an open channel of communication is key. Let them know they can reach out if they have concerns or notice signs of regression. Depending on what works best for you and the family, you might set up a plan for periodic check-ins via phone, email, or even text. This continued support can be very reassuring for parents.
Educate on Red Flags and Signs of Regression
Part of the discharge process should include educating parents on potential red flags or signs of regression. Ensure they know what to watch for and understand that, if necessary, a re-evaluation can be conducted to determine if OT services should be reinstated. Providing this information helps parents feel more in control and prepared.
Documenting Sensory Integration Interventions
Documenting sensory integration interventions requires special attention to detail. When you use sensory integration techniques, it’s crucial to describe the sensory experiences provided, the student's response, any adaptive responses elicited, and the impact on functional skills and participation. Your documentation should clearly demonstrate the skilled services you provided and the progress made by the student. Using precise language and providing measurable outcomes will ensure that your interventions are well-justified and understood by all stakeholders.
By following these tips, you can make the discharge process a positive and supportive experience for both the student and their family, ensuring that they continue to thrive even after OT services have concluded.
Documenting Sensory Integration (SI) Interventions
Documenting SI interventions requires careful attention to detail. You must clearly describe the specific sensory systems targeted, the student’s response, and how these interventions impact the student’s functional performance in school. For instance, instead of simply stating that "Susan used the swing for 10 minutes of vestibular input," a better note would explain how the vestibular input affected Susan's ability to focus in class afterward.
SI documentation should also include objective measurements of progress whenever possible. This might involve recording the duration of exposure to specific sensory stimuli, the student’s adaptive responses, and how these interventions contribute to their goals.
Discharge Planning
Discharge should be a positive milestone for the student and their family. A comprehensive discharge report will summarize the student’s progress and recommendations for continued support, such as after-school programs or home activities. Providing caregivers with handouts or training to continue supporting the student’s development post-discharge is also important.
When discharging a student, it’s helpful to provide parents with community resources, such as gymnastics or dance classes, that align with the student’s therapy goals. This can help ease the transition out of OT and ensure that the student continues to develop the skills they’ve gained during therapy.
Conclusion
Effective documentation is essential to communicate the value of OT services and justify their necessity in a student's educational environment. By following the strategies discussed in this course—such as writing clear, measurable goals, avoiding common documentation mistakes, and documenting sensory integration interventions in detail—you can improve the quality of your documentation while reducing the time it takes to complete it.
With practice and structured templates, documenting your work will become easier, faster, and more effective.
Exam Poll
1)What should documentation reflect?
It is all of the above. Your documentation should reflect the nature of services and the response to intervention, but you also have to talk about the relationship of the services to the goals.
2)Which of the following is a common mistake while writing evaluation reports?
The interventions listed don't reflect the need for skilled services is the correct answer. That is definitely a common mistake.
3)When is a re-evaluation indicated?
When new findings occur, you will have to perform a comprehensive re-evaluation because that could significantly impact the treatment plan and the goals you have set for the student.
4)What is a common mistake while writing intervention plans?
When you change the frequency and duration of treatment, you have to specify why you're doing that. You have to provide reasons for doing that.
5)Which of the following is an effective goal showing allowed assistance?
The correct answer is C.
Questions and Answers
In Wisconsin, we're not allowed to observe or do anything regarding the student until consent is received from the parents or guardians, and we do not do screening reports. Is this different in California?
Yes, the process is different in California. Typically, when I receive a referral for OT in any of the districts I’ve worked in, I send a letter to the parents requesting permission to perform the screening. Once I receive consent, I proceed with the screening. After the screening, I send home a letter summarizing whether or not the child will be receiving a comprehensive OT evaluation. Each state has its own guidelines, so it’s important to follow local regulations.
Where is a good place to get templates for treatment notes?
You can visit TotalReport, which I founded for this exact purpose. When I was a new OT in schools, I struggled to find templates that suited the needs of the school-based setting. After searching without satisfactory results, I created TotalReport to provide OTs with the support and resources needed, including templates for treatment notes tailored to the school environment.
References
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Citation
Kuruvilla, K. (2024). Documentation in school-based occupational therapy. OccupationalTherapy.com, Article 5731. Available at www.occupationaltherapy.com
