Pediatric Physical Therapy Intervention Activities



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 |Type of Activity: | |

|Neuromuscular Interventions: |Enter the duration of each activity in |No services this week per IEP plan ____; |

|Balance |5-minute increments. | |

|Postural awareness | |Absence of Student___; Absence of PT/PTA___; |

|Motor learning |Pre-Functional      minutes | |

|Hands-on facilitation techniques | |School closed____; Schedule conflict____; |

|Constraint-induced MT |Sitting      minutes | |

|Oral motor facilitation | |Other (note)_________________________________ |

|Aquatic therapy |Standing      minutes | |

|Musculoskeletal Interventions: | |Interventions: |

|Strengthen (PRE) |Transitions &      minutes |Enter one 2-digit INTERVENTION CODE |

|Strengthen (Functional) |Transfers |per box |

|PROM/Brief Stretch | | |

|Prolonged Stretch |Classroom Activity 10 minutes ||03| |66| |22| |04| |62| |

|Manual Therapy | | |

|Massage |Classroom Mobility      minutes ||70| |01| |09| |70| |  | |

|Use of modality:       | | |

|Cardiopulmonary Interventions: |School Mobility      minutes ||  | |  | |  | |  | |  | |

|Breathing |Indoors | |

|Aerobic/conditioning ex. | ||  | |  | |  | |  | |  | |

|Postural Drainage |School Mobility 10 minutes | |

|Integumentary Interventions: |Outdoors ||  | |  | |  | |  | |  | |

|Pressure release | | |

|Position changes |Community Mobility      minutes ||  | |  | |  | |  | |  | |

|Skin checks | | |

|Orthoses: | | |

|Shoe insert |PE/Recreation ||  | |  | |  | |  | |  | |

|LE plastic orthoses:       |Activity 10 minutes | |

|Knee Immobilizer | ||  | |  | |  | |  | |  | |

|Trunk orthosis (elastic) |Self-Care Activity 10 minutes | |

|Elbow/Hand splint | ||  | |  | |  | |  | |  | |

|Taping |Communication      minutes |__________________________________________ |

|Elastic wraps/suits | |Services Delivered by: (check one) |

|Mobility Assistive Devices: |Other Activity      minutes | |

|BWS harness system | |PT:       PTA:       Both PT & PTA: X |

|Treadmill |Describe:            | |

|Wall/railing/furniture for support | |Notes: _______________________ |

|Push toy |Total Time with Student: 40 min. |_____________________________ |

|Walker, type:       | | |

|Crutches, type:       | | |

|Canes, type:       | | |

|Dowels/sticks | | |

|Wheelchair, type:       | | |

|Mobility Interventions: | |Service Delivery Duration: (5-minute increments) |

|Hall training |Sensory Interventions: | |

|Stairs training |Visual training |Services to the Student: |

|Doors training |Sensory integration ex. | |

|Curbs training |Sensory processing |A. Individual: |

|Bus/car training |Educational Interventions: |20 |

|Ramp training |Student | |

|Elevator training |Family/caregiver |Group: 20 |

|Bathroom access |Teacher |B. With students who are non-SpEd: 10 |

|Cafeteria access |PT Assistant | |

|Library access |Aide |With students who are SpEd: 30 |

|Playground access |IEP Team |With students in both SpED/non-SpED:       |

|Positioning & Devices: |Other       | |

|Seating |Assessment: |With no other students:       |

|Sidelyers |Major |C. Within a school activity: 10 |

|Standers: prone, supine |Ongoing | |

|Prone over wedge |Other Interventions |Separate from school activity: 30 |

|Other       |Fine motor |D. Co-treatment: 0 |

|Equipment Interventions: |Cognitive training | |

|Equipment Application/training |Behavioral training |With whom: OT:__ SLP:__ Teacher:__ Aide:__Other:__ |

|Equipment Maintenance |Speech/Language | |

|Equipment Fabrication |Social/Emotional |Not in Co-treatment: 40 |

|Adapted switches/toys |Adaptive PE |Services on behalf of the Student: |

|Communication Devices |Orientation and Mobility | |

|Other       |Other       |E. Consultation/Collaboration: 10 |

| |Other       | |

| | |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 |

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