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:
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:
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 ____;
Absence of Student___;
School closed____;
Pre-Functional
minutes
Sitting
minutes
Standing
minutes
Transitions &
Transfers
minutes
Absence of PT/PTA___;
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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Classroom Activity 10 minutes
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Classroom Mobility
minutes
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School Mobility
Indoors
minutes
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School Mobility
Outdoors
Community Mobility
10 minutes
minutes
PE/Recreation
Activity
10 minutes
Self-Care Activity
10 minutes
Communication
minutes
Other Activity
minutes
Describe:
Total Time with Student: 40 min.
__________________________________________
Services Delivered by: (check one)
PT:
PTA:
Both PT & PTA: X
Notes: _______________________
_____________________________
Service Delivery Duration: (5-minute increments)
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 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:
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