Best Practices for Service Documentation
In the world of IDEA, documentation is a requirement. However, documentation practices in school districts have no universal standard. This can lead to major problems both for students and districts ― like due process hearings and issues with continuity of service. So, in the absence of universal standards, your district should create best practices of its own. Here is some information to help you get started.
School-based health services documentation serves multiple purposes. Each purpose must be examined to create a comprehensive approach to best practices.
The primary role of documentation is to monitor and assess student progress, both to communicate with other therapists and present to parents and school administrators. Documentation must also adhere to state-specific Medicaid requirements to support billing. Finally, in a due process hearing, consistent and thorough documentation is vital to support decisions made toward a student’s special education treatments and determination.
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As you examine service documentation practices in your school district, these questions can guide your strategy:
Does my district have standards for therapy documentation? Do all therapy groups practice the documentation standards?
Does the documentation in my district meet the requirements for IDEA? Does it meet license requirements within each scope of practice?
Does the documentation in my district meet the requirements for Medicaid billing? Will the documentation fully support the district in case of an audit?
Is there a central location for all of our service documentation? Can case managers access this information during IEP or other special education meetings? Can administrators access this documentation as needed for due process or other legal proceedings?
Is there any impediment to implementing a universal standard to documentation in my district? How can I incentivize therapists to adopt these practices?
- The purpose of the session
- The date and start time
- Progress monitoring data, including the level of assistance, the student progress towards the goal for the session and any recommendations for future services
- Cancellation documentation
- Specific identification of interventions
- Current patient impairment or disability status
- Communication or consultation with other stakeholders
- A signature, title and license number
- In addition, it is recommended the documentation be completed as close to the session as possible
- The student’s identifying information
- The date of the service
- Service location
- Procedure code
- Diagnostic code
- A description of the session
Documentation standards across common school-based therapy types
The main therapy associations all provide standards for documentation within their specialty. Examining the varying standards helps administrators create a unified approach to documentation in their school districts.
According to the American Speech-Language-Hearing Association (ASHA), the base requirements for documentation include:
The American Physical Therapy Association and American Occupational Therapy Association include the same requirements as ASHA but expand their standards to include:
The common theme for documentation in all practices is the development of a SOAP, or a comment that includes Subjective (S), Objective (O), Assessment (A) and Plan (P) data, to allow other therapists to quickly grasp the student’s progress and current status.
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Medicaid documentation requirements
Medicaid documentation requirements can vary within each state, but generally include:
The below table shows the various requirements around service documentation and Medicaid requirements surrounding IDEA documentation in sample states:
Benefits of a single, central documentation system
Documentation is only as useful as it is accessible. If we revisit the primary goal of documentation ― to assess student progress ― the means of delivering this information to other therapists and administrators or parents is best handled in a universal manner.
Caseloads shift. Students change schools year over year, or mid-year. When that happens, access to prior treatments, methods, and a thorough understanding of the student’s present levels will allow therapy to remain consistent and protect against the risk of deterioration of functionality.
A central system that manages this Medicaid service data and provides instant access mitigates risks when therapists are no longer employed by the district, go on leave, or simply don’t have time to collect and send therapy summaries to the new therapist.
In the case of due process, documentation is paramount to preventing due process cases and reducing the timeline of proceedings. Findings by the Los Angeles Times report that school districts in California have seen an increase in due process cases from below 3,000 in the 2010-2011 school year to nearly 5,000 in the 17-18 school year.
Schools are commonly asked to pay not only for legal teams to protect themselves but are often obligated to pay the legal team hired by the parent. Due process legal fees were reported as $610,000 annually for the San Diego Unified Schools, and Poway Unified paid $489,000 in legal fees for the district, in addition to $487,000 for parent generated legal fees. Due process settlements cost Poway $1.1 million.
School districts often settle ― even if they are in the right ― due to lengthy proceedings, but the best way to eliminate the cost of due process is to prevent the practices that lead to complaints in the first place. Documentation, not only of services provided but of services missed or cancelled, especially due to student absences, can build trust with parents through transparency.
“The best way to eliminate the cost of due process is to prevent practices that lead to complaints in the first place.”
How to start maintaining documentation standards
If your district doesn’t have best practices for documentation, collaboration with key stakeholders is the best way to begin the process. To start, include therapy leads in the conversation and get feedback on realistic timelines to implement new best practices.
Ensuring equitable treatment of providers is also important. Documentation should have a universal standard across all disciplines, so therapists feel they are being treated fairly in workload expectations. Education and incentivization are also excellent tools. A good first step in education is to review the documentation guidance issued by each therapy discipline.
Remember that stakeholders should be fluent in the various license and regulatory requirements that support universal service documentation. In addition, giving providers some transparency into your district’s due process budget and its impact on staffing levels, salaries and professional growth support can help therapists and other special education stakeholders understand why a best practice approach to documentation is vital to your district.
Finally, make sure you recognize individuals who exemplify your documentation standards. You can do this by using contests or opportunities for public recognition. These incentives will reward work well done and provide therapists with tangible examples that the documentation practices your district chooses are achievable.
 The American Speech-Language-Hearing Association. (n.d.). Documentation in Schools. Retrieved from: https://www.asha.org/PRPSpecificTopic.aspx?folderid=8589942597§ion=Key_Issues
American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68, S1–S48. https://doi.org/10.5014/ajot.2014.682006
 New Mexico Human Services Department Medical Assistance Division School Health Office. (2014). New Mexico Medicaid Guide for School Based Services. Retrieved from: https://www.hsd.state.nm.us/uploads/files/Looking%20For%20Information/Information%20for%20Recipients/Special%20Programs%20and%20Waivers/School-Based%20Health%20Overview/MSBS%20Guidebook%20Jan%202014%20Updates%20Final%20010914.pdf
 The Los Angeles Times. (2019). Families endure costly legal fights trying to get the right special education services. Retrieved from: www.latimes.com/california/story/2019-10-06/legal-fights-families-special-education-services