PT Session Notes in Schools: What to Include

The note says: "Gait training, 30 minutes." It is signed and dated. It does not say what the student practiced, how much help was needed, which goal it served, or what changed since last week. In a school, the next reader is a teacher, a parent, or a reviewer who was not in the gym.

School PT sits between two sets of expectations. The IEP says what the student needs to take part in school. The profession's own documentation guidelines say what a visit note should hold. A good school note serves both. This guide draws on APTA's documentation guideline, a fact sheet from the Academy of Pediatric Physical Therapy, and Illinois's recommended practices for school therapy.

Who decides the format

The Academy of Pediatric Physical Therapy's fact sheet is blunt about it. Requirements for school PT intervention records are not stipulated in IDEA. Districts, supervisors, or therapists determine the format and extent of the documentation, usually based on state practice acts and the guidelines of their professional organizations.

The same fact sheet describes how the IEP fits. The IEP is the foundation for service delivery. It includes present levels of academic achievement and functional performance, measurable goals, methods for monitoring progress, and the related services to be provided, including their frequency and duration. IEP goals must be discipline-free, measurable, and focused on the student's participation in the educational program, and PT intervention strategies are not documented in the IEP. Whether the IEP also serves as the plan of care depends on state regulations.

So your notes are where the PT intervention actually lives. They carry what the IEP does not.

What APTA says a visit note does

APTA's guideline says documentation of a visit, often called a progress note or daily note, documents the sequential carrying out of the plan of care, including changes in the person's status and variations and progressions of specific interventions. It may also include specific plans for the next visit or visits. It also says documentation is required for every visit, and that it should include no-shows and cancellations.

Equipment, positioning, and safety

Mobility and positioning are central to many school PT caseloads, and the record should show them. The Illinois recommended practices list positioning programs among the records a therapist keeps, and they suggest recording equipment issued with instructions for its use. APTA's guideline describes examination findings about assistive and adaptive devices as including their alignment, fit, and safety during use. In a note, that translates into plain facts: the device, how it was set up, and whether it was used safely.

If a student's health or medical situation changes, the Illinois document says to consider factors such as the student's health, precautions and safety concerns, and new or recurring medical issues when deciding whether to contact the student's health care professional. Write what you observed and who you told.

A sample entry

Notice what it does not say: no diagnosis, no guesswork, and no comparison with other students.

Measuring progress

The Illinois recommended practices say progress toward IEP goals is measured against criteria set by the team, and that mastery criteria can be time, distance, repetitions, percentages, accuracy, completion of trials, or quantified assistance levels as stated in the IEP. Distance and time suit many PT goals. A 2016 study in Pediatric Physical Therapy looked at 296 students and found that school physical therapists converted IEP goals into scaled subgoals at the start of the year and scored them at the end, which is one way to track a goal that does not reduce to a single count. See rating scales in session notes.

Cancellations and missed visits

APTA says to record no-shows and cancellations. In a school, that means a short entry for a student who was absent, a school event, a drill, or a session you could not hold. Include the date and the reason, and say whether a make-up was arranged. The reasons you use should be the same words every time. Documenting make-up sessions goes through the wording.

Authentication and corrections

APTA's guideline says that entries in visit notes are dated and authenticated by the physical therapist or physical therapist assistant who provided the service, with their full name and appropriate designation. It says documentation by students has to be additionally authenticated. How assistants may sign in your state depends on state law. See signatures and credentials on school therapy notes.

For corrections, APTA says a handwritten error should have a single line drawn through it, with initials and a date, or an electronic mechanism that makes clear a change was made without deleting the original. The point is that a reader can see the correction and the original.

Medicaid paperwork

The Academy's fact sheet says that when a district seeks Medicaid reimbursement, Medicaid-specific paperwork is required of the school PT for each session, usually in the language of medical necessity, and that requirements vary by state. Your billing office will tell you what is needed. Many of the facts above, such as the date, duration, and the service delivered, are the ones it will ask for. See school Medicaid documentation basics.

PT-note slips

• An intervention with no goal. A reader should see which IEP goal the session supports.
• No assistance level. The same distance with a gait trainer and with a walker are different results.
• Equipment not mentioned. The device and its set-up belong in the note.
• Leaving out the cancellation. A missed visit is part of the record.
• Overwriting an error. Use a visible correction.

Terms are in the glossary.