School Physical Therapy Interventions for Pediatrics (S-PTIP) Data Form McCoy, Jeffries, Effgen, Chiarello, Gregory, Smarrs, Stoner 2/15/2012 Student ID _EX1 Monday date for Week Reported 11/14/11 Therapist ID 00 No Services Due to: (check one below) INTERVENTION CODES Neuromuscular Interventions: 1. Balance 2. Postural awareness 3. Motor learning 4. Hands-on facilitation techniques 5. Constraint-induced MT 6. Oral motor facilitation 7. Aquatic therapy Musculoskeletal Interventions: 8. Strengthen (PRE) 9. Strengthen (Functional) 10. PROM/Brief Stretch 11. Prolonged Stretch 12. Manual Therapy 13. Massage 14. Use of modality: Cardiopulmonary Interventions: 15. Breathing 16. Aerobic/conditioning ex. 17. Postural Drainage Integumentary Interventions: 18. Pressure release 19. Position changes 20. Skin checks Orthoses: 21. Shoe insert 22. LE plastic orthoses: 23. Knee Immobilizer 24. Trunk orthosis (elastic) 25. Elbow/Hand splint 26. Taping 27. Elastic wraps/suits Mobility Assistive Devices: 28. BWS harness system 29. Treadmill 30. Wall/railing/furniture for support 31. Push toy 32. Walker, type: 33. Crutches, type: 34. Canes, type: 35. Dowels/sticks 36. Wheelchair, type: Mobility Interventions: 37. Hall training 38. Stairs training 39. Doors training 40. Curbs training 41. Bus/car training 42. Ramp training 43. Elevator training 44. Bathroom access 45. Cafeteria access 46. Library access 47. Playground access Positioning & Devices: 48. Seating 49. Sidelyers 50. Standers: prone, supine 51. Prone over wedge 52. Other Equipment Interventions: 53. Equipment Application/training 54. Equipment Maintenance 55. Equipment Fabrication 56. Adapted switches/toys 57. Communication Devices 58. Other
Type of Activity: Enter the duration of each activity in 5-minute increments.
No services this week per IEP plan ____;
Pre-Functional
minutes
Other (note)_________________________________
Sitting
minutes
Standing
minutes
Transitions & Transfers
minutes
Absence of Student___; School closed____;
Absence of PT/PTA___;
Schedule conflict____;
Interventions: Enter one 2-digit INTERVENTION CODE per box
|03| |66| |22| |04| |62| |70| |01| |09| |70| | |
Classroom Activity 10 minutes
| | | | | | | | | |
Classroom Mobility minutes
| | | | | | | | | |
School Mobility Indoors
minutes
| | | | | | | | | |
School Mobility Outdoors
10 minutes
| | | | | | | | | |
Community Mobility minutes
| | | | | | | | | |
PE/Recreation Activity
10 minutes
| | | | | | | | | |
Self-Care Activity
10 minutes
Communication
minutes
Other Activity
minutes
Describe:
Total Time with Student: 40 min.
Sensory Interventions: 59. Visual training 60. Sensory integration ex. 61. Sensory processing Educational Interventions: 62. Student 63. Family/caregiver 64. Teacher 65. PT Assistant 66. Aide 67. IEP Team 68. Other Assessment: 69. Major 70. Ongoing Other Interventions 71. Fine motor 72. Cognitive training 73. Behavioral training 74. Speech/Language 75. Social/Emotional 76. Adaptive PE 77. Orientation and Mobility 78. Other 79. Other
| | | | | | | | | | __________________________________________ Services Delivered by: (check one) PT: PTA: Both PT & PTA: X
Notes: _______________________ _____________________________ Service Delivery Duration: (5-minute increments) Services to the Student: A. Individual: 20 Group: 20 B. With students who are non-SpEd: 10 With students who are SpEd: 30 With students in both SpED/non-SpED: With no other students: C. Within a school activity: 10 Separate from school activity: 30 D. Co-treatment: 0 With whom: OT:__ SLP:__ Teacher:__ Aide:__Other:__ Not in Co-treatment: Services on behalf of the Student:
40
E. Consultation/Collaboration: 10 With whom: Family:____ Staff:____ Others:____ F. In-service: G. Curriculum development: H. Documentation Time:
35
I. Total Services on behalf of Student: 45 Setting: School _X_; Home ___; Other (note) _______ Student Participation Rating: 0----—1—----2—----3—----4—----5-------6