School Physical Therapy Interventions for Pediatrics (S-PTIP) Data Form

McCoy, Jeffries, Effgen, Chiarello, Gregory, Smarrs, Stoner2/15/2012

Student ID _EX1Monday date for Week Reported 11/14/11 Therapist ID 00 No Services Due to: (check one below)

INTERVENTION CODES
Neuromuscular Interventions:
01.Balance
02.Postural awareness
03.Motor learning
04.Hands-on facilitation techniques
05.Constraint-induced MT
06.Oral motor facilitation
07.Aquatic therapy
Musculoskeletal Interventions:
08.Strengthen (PRE)
09.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: / Type of Activity:
Enter the duration of each activity in 5-minute increments.
Pre-Functional minutes
Sitting minutes
Standing minutes
Transitions & minutes
Transfers
Classroom Activity 10 minutes
Classroom Mobility minutes
School Mobility minutes
Indoors
School Mobility 10 minutes
Outdoors
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. / No services this week per IEP plan ____;
Absence of Student___; Absence of PT/PTA___;
School closed____; Schedule conflict____;
Other (note)______

Interventions:

Enter one 2-digit INTERVENTION CODE
per box
|03| |66| |22| |04| |62|
|70| |01| |09| |70| ||
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______
Services Delivered by: (check one)
PT: PTA: Both PT & PTA:X
Notes: ______
______
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 / 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
  1. Fine motor
72.Cognitive training
73.Behavioral training
  1. Speech/Language
  2. Social/Emotional
  3. Adaptive PE
  4. Orientation and Mobility
  5. Other
  6. Other
/

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: 40

Services on behalf of the Student:

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:
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