Documentation & Data Collection For Pediatric Occupational Therapy
08.09.2016
There are many different types of documentation a pediatric Occupational Therapist completes throughout a typical work day. These may include: Referral for Service, Progress Note, Daily Contact Note, Quarterly Note, Evaluation Report, Consultation Note, Intervention Plan, Supervision Note, Attendance Records, and Discontinuation Summaries. Regardless of the type of documentation, certain conventions for good documentation must occur.
This blog will explore documenting ongoing intervention and progress in Pediatric Occupational Therapy. It will focus on: (1) Benefits and Accountability of Data Collection, (2) Considerations for Data Collection, (3) Principles of Data Collection, and finally (4) Documentation and Data Collection Resources Tools to Grow has to offer.
Accountability & Other Benefits for Progress Monitoring
Data Helps Justify Treatment Decisions:
To be accountable, it is assumed that clinical decisions regarding treatment efficacy should be based on data. This quantitative and qualitative information should provide evidence for deciding the course of treatment. Data not only allows for examination of the child’s response to past treatment decisions, it helps guide future treatment planning.
Proper data collection tools are necessary to make ongoing clinical decisions concerning client progress in treatment. Effective progress monitoring provides the basis for informed decisions about instruction/intervention. Data can help answer the following questions:
Is the child responding positively to the current treatment?
- Does the data accurately measure the child’s performance on targeted goals and objectives?
- To be useful the data collected also needs to reflect the child’s response to a variety situations. Can information regarding the child’s variable response(s) and performance from session to session be recorded?
Is measurable change occurring?
- Data should help determine if the child is changing and if the rate of change is faster than what would have occurred without therapeutic intervention.
- Is the change sufficient to meet the targeted goals within the predicted time frame?
- Finally, is the change sufficient to improve the child’s quality of life and help him/her succeed within their occupational role?
Is the Occupational Therapy treatment responsible for the change?
- Data can help verify that the child’s change is due to the treatment itself and not due to other influences.
How long should this goal or treatment focus be targeted?
- On a client by client basis, the therapist needs to determine if the focus of the child’s therapy will be to promote the emergence of a targeted skill/behavior, promote the mastery of a targeted skill/behavior, or maintain a skill/behavior.
- Treatment should only be provided as long as necessary; treatment data results should be part of the information that is used to determine the duration of a targeted intervention or the continuation of Occupational Therapy services.
Data Is Required for Third party Involvement:
Data is expected to convince third party insurers that treatment is effective and hopefully producing progress. Data is used to document the efficacy of Occupational Therapy services for reimbursement.
Data is Important when Reporting Progress to Parents/Caregivers:
Offering parents/guardians the results of reliable data is important when communicating about their child’s response to Occupational Therapy treatment.
Data and the Role of Professional Clinical Judgment:
Most therapists would agree that data cannot be collected on every aspect of a child’s intervention process and that clinical judgment is often indicated. Nonetheless, decisions regarding whether or not treatment is achieving the targeted results should include information from both qualitiative and quantitative recorded data.
Considerations for Data Collection
Given the variety of treatment situations, the data that is collected should also be designed to be suitable for the given scenario. Data can be either quantitative or qualitative. Both types of data are important for documenting a child’s change and attaining an overall view of the child.
Quantitative data refers to objective data, where overt behaviors can be observed, and counted (measured). The critical feature of quantitative data is that a behavior can be described so precisely that at least two independent observers could observe and count occurrences of the behavior, for example the use of a fine pincer grasp to pick up tiny objects.
Qualitative data refers to subjective data. This includes observations using session notes, interviews, questionnaires, and other sources (work samples). Qualitative data reflects the therapist’s subjective views and interpretation, such as how a child maintains self-regulation in a challenging sensory environment.
Principles of Data Collection
- Validity: This refers to the truthfulness of the data; does the data accurately measure the targeted behavior? To do so it is necessary to have adequate amounts and a variety of data.
- Reliability: This refers to the trustworthiness of the data. The data do not merely reflect what is in the clinician’s mind, but rather that others can trust in the way the data have been collected and analyzed. Data is best collected in real time as you are observing the child’s behavior. Waiting to record the data sometime after the observation can result in errors.
- Ease of Collection: For an overall picture of a child, it is desirable to collect both quantitative and qualitative data; but given the demands of most clinical positions, collection of only the most necessary data is practical.
The 3 W’s of Data Collection- What, When & Where:
- Data from Performance Tasks- Using goals that are written to measure a student’s performance on a specific behavior/skill/task, the therapist can determine a success rate by comparing the total number of correct responses to the total number of responses measured.
- Therapy sessions- Treatment data are those data gathered while treatment is occurring; in this case the situation may be considered contrived, as the child’s response is influenced by the therapist (via modeling, physical facilitation, environmental modifications, etc.). This data reflects the child’s performance during intervention. The quantitative data may be the pluses and minuses that therapists tally on their documentation forms. An example may be the number of times a child copies a given geometric shape from a visual model. The qualitative data collected during therapy may reveal if the child is attending and participating. It is significant to note that treatment data does not reflect how the child is generalizing the targeted skill or behavior into other situations, this data is restricted to the therapy situation.
- Naturally Occurring Observations- This type of generalization data is collected “outside” of the therapy situation with the intent to capture the child’s performance in a more natural setting. The situation would include new people, new materials, and/or new settings.
- Frequency of Data Collection- Data should be collected in a planned and consistent basis.
Documentation and Data Collection Resources
We have the perfect tools for planning and documenting your therapeutic interventions. We hope these forms help to make your job easier! This will give you time to focus on what is important ... helping children grow!
1. ASSESSMENT CHECKLISTS:
For some situations, a combination of standardized and non-standardized tests is appropriate, but at times norm-referenced tests are neither valid nor meaningful. In this case, data gathered from non-standardized measures provide the essential information needed for assessment and planning intervention, as well as gathering and tracking the progression of skills.
The following assessment checklists will help a therapist verify and compare a child’s development in a variety of functional skill areas.
Occupational Therapy School Based Skills Checklist:
These informal School Based Skills checklists provide a valuable record for documenting a child’s progress in a variety of performance areas. Use these over and over when standardized testing is not indicated or suitable.
School Based Skills Checklists are organized into Three Different Age/Grade Ranges:
1. Occupational Therapy Skills Checklist: Kindergarten - 1st Grade
2. Occupational Therapy Skills Checklist: 2nd - 3rd Grade
3. Occupational Therapy Skills Checklist: 4th - 6th Grade
Each Skills Checklist is a comprehensive 9- 10 Page PDF that is divided into 14 Skill Sections:
- Prehension
- Manipulation
- Dominance
- Scissor Use
- Color
- Use Classroom Tools
- Bilateral Skills
- Draw
- Learning Concepts
- Handwriting
- Self Help
- Visual Perceptual (Includes 7 Sub-Sections)
- Outcomes of Sensory Processing/Attending Skills/Self-Regulation
- Gross Motor/Posture
- This 15 item Handwriting Checklist allows progress to be recorded each quarter.
- This 14 item Scissor Checklist is a great way to track and document the various criteria related to the progression of scissor skills.
- This skills checklist Includes 3 different Forms:
(1) Recognize Alphabet Checklist,
(2) Copy Alphabet Checklist, and
(3) Print Alphabet Checklist
Letters & Shapes Skills Checklist:
- This skills checklist Includes 3 different Forms:
(1) Upper Case Letters Checklist,
(2) Lower Case Letters Checklist, and
(3) Shapes Checklist
Visual Perceptual Skills Checklists:
These informal Visual Perceptual Skills checklists provide a valuable record for documenting a child’s progress in a variety of Visual Perceptual performance areas. Use these over and over when standardized testing is not indicated or suitable.
The Visual Perceptual Skills Checklist is a comprehensive 7 Page PDF that is divided into three sections:
- Preschool - 1st Grade
- 2nd Grade - 3rd Grade
- 4th Grade - 6th Grade
Read out blog post on Visual Perception: Possible Impact on a Child’s Success at School & Home here!
Early Childhood Self-Help Skills Checklist:
Quick screen for therapists to assess developmental status of self-help skills. Organized into age ranges 12-18 months, 18-24 months, 24-30 months, 30-36 months, 3-4 years, 4-5 years, and 5-7 years. Conveniently organized into Sub-Sections, which Include:
- Self-Dressing Skills,
- Feeding Skills,
- Toileting Skills, and
- Personal Hygiene/Grooming Skills.
Early Childhood Skills Checklist:
Perfect for Early Intervention therapists! This Occupational Therapy Early Childhood Skills Checklist is for children age 0 - 60 months. Sub-sections for children ages newborn to 5 years old. This checklist is the perfect quick screen for therapists to assess developmental status of fine motor, visual motor, and self-help skills. Each page is organized into 3 month age ranges. Two versions/layout options available.
2. DOCUMENTATION FOR ONGOING INTERVENTION:
The intention of written documentation of ongoing intervention is to provide a record of intervention and progress. Documentation occurs in many formats, often following each intervention session, however may also be written weekly, quarterly, or another time interval.
Complete Consultations on this organized and high quality form! Includes Student Name, DOB, ID#, School, Teacher, Frequency, Therapist Name/License#, Date, Concerns, Strategies, and Follow up. Two different versions included.
This editable PDF is the perfect form to document a student's progress each quarter. Simply open and type right into the document. Includes section for Student's Name, School Year, DOB, ID#, Quarter, Diagnosis, Precautions, Therapist Name, Date of Report, Progress this Quarter, Current Level of Performance, and Needs/Plan.
Improve your effectiveness by using a step by step approach to help children reach therapeutic goals. Use this simple form for recording the child's progression during therapy. Helps with planning based upon individual needs, as well as follow-up based upon the child's response.
A daily progress note may also be referred to as a contact note. The emphasis is on what services are provided and reflect the student's/child's response to intervention during that day or intervention session. A daily note must include information about client's performance and how current performance is different from previous performance. The goal of an Occupational Therapy progress note is to establish that the skills of an OT Practitioner contributed to the child’s progress towards the goals in the intervention plan.
Daily Treatment and Goal Progress Monitoring Form:
This AMAZING Data Collection & Documentation Form is an EDITABLE PDF. Simply type right into PDF! This form Includes: Student Name, Month, School Year, DOB, Case ID, Gender, Service Level, Diagnosis/alerts, Treatment Setting, Provider, Provider License#, Referring Physician, ICD code, Goals/Objectives, Date of Service, Start/End Times, Treatment Code(s), Progress Note, and Progress/Goal Monitoring Table.
This form includes a header where you can CUSTOMIZE with the name of your clinic/school district.
Attendance logs are used to identify when the child/student had therapy, the occupational therapist working with the child/student, type of intervention, and duration. Attendance logs are often used for billing purposes.
Tools to Grow has two editable Attendance Log Forms:
1) Attendance - with Codes Added: Simply open Editable/Fillable PDF and type in information! Includes August 2016 - August 2017. You only have to type in your information once and it will transfer to each month. You can edit by typing in your name, school, and student's names. Attendance Codes are already entered for you!
2) Attendance - You Type in Codes: Simply open Editable/Fillable PDF and type in information! Includes August 2016 - August 2017. You only have to type in your information once and it will transfer to each month. You type in your name, school, student’s names, and Attendance Codes.
Using data tracking forms can show the progress a child/student is making on a specific goal in a very concise way. The advantages to using data monitoring forms to track progress include:
- they are easy to read
- provide solid objective data
- uses minimal space
- easy for a substitute therapist to know what to expect in next session
- provide reliable data that can be used to write progress summaries
Tools to Grow is pleased to provide Editable Goal Progress Monitoring: Data Collection Forms. This resource includes data monitoring tables and graphs where measurements can be recorded at intervals. This will allow for the reader to see at a glance whether progress is being made in that particular goal/area. This resource includes:
- Data Monitoring Table with 10 trials - 1 Goal per page
- Data Monitoring Table with 5 trials - 1 Goal per page
- Data Monitoring Table with 10 trials - 2 Goals per page
- Data Monitoring Table with 5 trials - 2 Goals per page
- Data Monitoring Graph
Each form is editable, which will allows the user to type directly into the forms. Typ in Student Name, DOB, School Year, School, Therapist, and Goal(s). Simply save PDF on your device, open PDF and type right into form!!
Occupational Therapy Supervision Forms:
Supervision involves "guidance and oversight related to the delivery of occupational therapy services, as well as the facilitation of professional growth and competence. It is the responsibility of the occupational therapist and the occupational therapy assistant to seek the appropriate quality and frequency of supervision to ensure safe and effective occupational therapy service delivery" (AOTA, 2009).
Occupational therapists and occupational therapy assistants must document a supervision plan and supervision contacts. According to the American Occupational Therapy Association, Documentation for supervision should include the:
(1) frequency of supervisory contact,
(2) method(s) or type(s) of supervision,
(3) content areas addressed,
(4) names and credentials of the persons participating in the supervisory process.
Tools to Grow is pleased to provide an Occupational Therapy Supervision Plan and Supervision Form. The Occupational Therapy Supervision Plan will allow you to document the frequency of supervision, methods and types of supervision, content areas, and how professional development will be promoted.
The Occupational Therapy Supervision Form, will allow you to document the names and credentials of the persons participating in the supervisory process, treatment plan, specify specifics regarding the treatment process, and affirm that the necessary “Under the Direction” supervision will occur between the OTR and COTA.
Be sure to read our Blog Post on Organization & Time Management Tips for Occupational Therapists. Tools to Grow has wonderful resources for organization to keep your therapy items and materials neat, orderly, and accessible, as well as time management tools for prioritizing, scheduling, and completing tasks.
If there is a specific documentation resource that you are looking for, please comment below or email us.
We hope that these documentation and data collection tools and resources help to make your job easier! This will give you time to focus on what is important ... helping children grow!
References
American Occupational Therapy Association. (2009). Guidelines for supervision, roles, and responsibilities during the delivery of occupational therapy services. American Journal of Occupational Therapy, 63, 797-803.
Bain, B., & Olswang L., (1994).Data Collection: Monitoring Children’s Treatment Progress. American Journal of Speech Language Pathology, 55-66.
Sames, K. (2010). Documenting Occupational Therapy Practice: Second Edition. Upper Saddle River, NJ: Pearson
Related Topics: Caseload Management, Documentation & Data Collection, School Based OT
