Are you new to the world of school-based physical therapy? Maybe you are a seasoned veteran of the school-based therapy world, but you are looking for a more efficient way to document? School-based physical therapy documentation (and occupational therapy) can prove to be challenge as most districts are not equipped with any sort of documentation system for pediatric therapists working in the school setting.
According to a school-based physical therapy APTA fact sheet “Requirements for documentation in school-based settings are challenging for SBPTs and add significantly to their workload, impacting service provision and caseload assignments. Frustration about paperwork has been described as one of the greatest professional challenges for SBPTs and an impetus for leaving school-based practice.”
School-Based Physical Therapy Documentation
As a school-based therapist you are working under IDEA and IDEA lays out a framework of documentation that must be completed under the law including evaluations, re-evaluations, progress notes, and IEPs. That being said, IDEA doesn’t stipulate how school-based therapist intervention documentation should be done.
As therapists we need to figure out how IDEA paperwork jives with our practice act requirements and medicaid billing requirements.
So, it’s important that therapists need to be familiar with their individual state’s practice act and regulations related to school services to ensure that documentation required by the local school district for the IEP is sufficient to meet all aspects of professional documentation in their state.
More Documentation Considerations
Along with any IDEA requirements and any practice act requirements, therapists must also consider best practices when it comes to documentation. Reaching out to professional organizations such as the APTA or AOTA can help with guidance in documentation.
APTA’s “Defensible Documentation for Patient/Client Management” states that PTs should document each PT session (including cancellations) and stipulates that the IEP may include the plan of care.
In regards to school-based physical therapy the APTA School-Based Physical Therapy: Conflicts Between Individuals With Disabilities Education Act (IDEA) and Legal Requirements of State Practice Acts and Regulation fact sheet that “Requirements of practice acts related to physical therapy documentation vary from state to state. In general, PTs must: (1) document every intervention session, (2) secure storage of records, and (3) provide copies of the documents to the families. “
Choosing A School-Based Physical Therapy Documentation System
With technology today, there are easier ways to make documentation more efficient. It is important that before you select any type of documentation that you are aware of what kind of security is in place in your district with the documentation programs you select.
School-Based Therapy Documentation Options
Paper and Pen – There is nothing wrong with this, if it is the option that you choose. It may not be nearly as efficient, but for some, it is still their best option. Others may choose to type up each individual note in a program such as Microsoft Word.
Microsoft OneNote – I personally am a huge fan of using OneNote. This option allows you to organize by section and create folders for each school or child. It literally can eliminate all paper based daily note documentation. It also allows you to easily import pictures and print from the internet directly into the note system. I’m telling you, this is beyond even documentation. You can literally move all of your files electronic. It was a GAME CHANGER for me. I put together a course on how I set it up and used it to help you get started with this option!
Here is how I set up and organized myself. More than even documentation, this is absolutely AMAZING for organization.
Google Suite– Some school systems are set up on Google Suite and therapists have found this to be an efficient way to coordinate and track all of their documentation required for school settings.
Want to really know how to dive into either Microsoft Suite or Google Suite and become extra efficient as a school-based therapist? You need to check out Pink Oatmeal’s course, Leveraging Technology for Efficiency for the School-Based Therapist. This course teaches you about keeping files and folders online, documentation, tracking data and lots of other pearls using technology you likely already have available to you!
School System Documentation – Some school systems have documentation systems where you are required to enter in information for Medicaid billing. In some cases this may be an efficient enough system for some therapists to use given their caseload and setting. Unfortunately, most times it’s not designed for a therapist, but more for entering notes.
Evaluation Documentation
Evaluation write-ups can take up a huge chunk of time for school-based physical therapists and occupational therapists.
There is good news on this front as a new app is in place in regards to making evaluations more efficient.
Double Time Docs (affiliate link) is an app out that allows you to check boxes instead of writing big sentences. The app does it for you. They offer a free trial. I’ve heard a lot of good things about saving time using this app. Once you are finished you are able to get your report in Microsoft Word format. They have options for OT’s, PT’s, and SLP’s.
Do you know of any other great documentation resources for school-based therapists? Let me know!