HENRICO COUNTY PUBLIC SCHOOLS by 0k15667O

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									                                   HENRICO COUNTY PUBLIC SCHOOLS
                                         PHYSICAL THERAPY
                                        Documentation of Service
                                         School Year - 2010-11

 Name _______________________       DOB ________ School __________________ Grade _____
 Disorder _______________________ Frequency _____________ Teacher ____________________
 Parent(s) ______________________________________________       IEP Date _______________
 Parent(s) Phone #(s)____________________________ Medicaid # _________________________
 Physical Therapy ____________________________________          ReEval Due _____________
 Adaptive Equipment _________________________________________________________________

     1 2    3 4    5   6   7 8   9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
July
Aug
Sept                   H
 Oct                                  H
Nov   H                               h                                            H H
Dec                                                                 H H H H H            H H H H H
 Jan                                                      H                                      H
Feb                                                                     H
Mar                                                   H
Apr h                                                         H H H H H
May                                                                                                  H
June                                                      h

 Key:    x = Therapy Session                   SA = Student Absent          TA = Therapist Absent
         NS = Not seen (see comments)          H = Student Holiday          h = Half Day
         SC = School Closed – weather, etc.    SD = Staff Development       C = Communication with
         I = Individual                        G = Group                    parent or professional
         U = Unavailable                Bold = Medicaid/Med Online          (not billable)

 Student Objectives with Achievement dates:
 1. The student will

 2. The student will

 3. The student will

 4. The student will

 5. The student will

 6. The student will

 7. The student will

 8. The student will


 ___________________________                         ________________________________
 Therapist/Assistant Signature and Title             Printed Name and Title                    Initials

 _____________________________________               _________________________________________
 Supervising Therapist Signature and Title           Supervising Therapist Printed Name/Title Initials
Student Name:                           Medicaid #:                                 Month / Year:

 Date    *Type of    Short Term       Therapeutic Activity                    Student Response to Treatment   Initials
         Contact     Goal                                                         (must be measurable)
                     Addressed (#)
                                     Gait                    Strengthening
                                     Balance                 Coordination
                                     W/C Mgmt.               Motor Planning
                                     Transfers               Ex. Program
                                     Instruction of Staff / Caregiver
                                     _______________________________

                                     Gait                    Strengthening
                                     Balance                 Coordination
                                     W/C Mgmt.               Motor Planning
                                     Transfers               Ex. Program
                                     Instruction of Staff / Caregiver
                                     _______________________________

                                     Gait                    Strengthening
                                     Balance                 Coordination
                                     W/C Mgmt.               Motor Planning
                                     Transfers               Ex. Program
                                     Instruction of Staff / Caregiver
                                     _______________________________

                                     Gait                    Strengthening
                                     Balance                 Coordination
                                     W/C Mgmt.               Motor Planning
                                     Transfers               Ex. Program
                                     Instruction of Staff / Caregiver
                                     _______________________________

                                     Gait                    Strengthening
                                     Balance                 Coordination
                                     W/C Mgmt.               Motor Planning
                                     Transfers               Ex. Program
                                     Instruction of Staff / Caregiver
                                     _______________________________

                                     Gait                    Strengthening
                                     Balance                 Coordination
                                     W/C Mgmt.               Motor Planning
                                     Transfers               Ex. Program
                                     Instruction of Staff / Caregiver
                                     _______________________________

                                     Gait                    Strengthening
                                     Balance                 Coordination
                                     W/C Mgmt.               Motor Planning
                                     Transfers               Ex. Program
                                     Instruction of Staff / Caregiver
                                     _______________________________

                                     Gait                    Strengthening
                                     Balance                 Coordination
                                     W/C Mgmt.               Motor Planning
                                     Transfers               Ex. Program
                                     Instruction of Staff / Caregiver
                                     _______________________________

                                     Gait                    Strengthening
                                     Balance                 Coordination
                                     W/C Mgmt.               Motor Planning
                                     Transfers               Ex. Program
                                     Instruction of Staff / Caregiver
                                     _______________________________



Supervising Therapist Signature /Title and Date: ____________________________________________
Therapy Assistant Signature /Title and Date: _______________________________________________
* Type of Contact: I = Individual  G =Group SA = Student Absent TA = Therapist Absent SU = Student Unavailable
                    TU= Therapist Unavailable C = Communication w/ parent or professional (not billable)
Student Name:                           Medicaid #:                                 Month / Year:

 Date    *Type of    Short Term       Therapeutic Activity                    Student Response to Treatment   Initials
         Contact     Goal                                                         (must be measurable)
                     Addressed (#)
                                     Gait                    Strengthening
                                     Balance                 Coordination
                                     W/C Mgmt.               Motor Planning
                                     Transfers               Ex. Program
                                     Instruction of Staff / Caregiver
                                     _______________________________

                                     Gait                    Strengthening
                                     Balance                 Coordination
                                     W/C Mgmt.               Motor Planning
                                     Transfers               Ex. Program
                                     Instruction of Staff / Caregiver
                                     _______________________________

                                     Gait                    Strengthening
                                     Balance                 Coordination
                                     W/C Mgmt.               Motor Planning
                                     Transfers               Ex. Program
                                     Instruction of Staff / Caregiver
                                     _______________________________

                                     Gait                    Strengthening
                                     Balance                 Coordination
                                     W/C Mgmt.               Motor Planning
                                     Transfers               Ex. Program
                                     Instruction of Staff / Caregiver
                                     _______________________________

                                     Gait                    Strengthening
                                     Balance                 Coordination
                                     W/C Mgmt.               Motor Planning
                                     Transfers               Ex. Program
                                     Instruction of Staff / Caregiver
                                     _______________________________

                                     Gait                    Strengthening
                                     Balance                 Coordination
                                     W/C Mgmt.               Motor Planning
                                     Transfers               Ex. Program
                                     Instruction of Staff / Caregiver
                                     _______________________________

                                     Gait                    Strengthening
                                     Balance                 Coordination
                                     W/C Mgmt.               Motor Planning
                                     Transfers               Ex. Program
                                     Instruction of Staff / Caregiver
                                     _______________________________

                                     Gait                    Strengthening
                                     Balance                 Coordination
                                     W/C Mgmt.               Motor Planning
                                     Transfers               Ex. Program
                                     Instruction of Staff / Caregiver
                                     _______________________________

                                     Gait                    Strengthening
                                     Balance                 Coordination
                                     W/C Mgmt.               Motor Planning
                                     Transfers               Ex. Program
                                     Instruction of Staff / Caregiver
                                     _______________________________



Supervising Therapist Signature /Title and Date: ____________________________________________
Therapy Assistant Signature /Title and Date: _______________________________________________
* Type of Contact: I = Individual  G =Group SA = Student Absent TA = Therapist Absent SU = Student Unavailable
                    TU= Therapist Unavailable C = Communication w/ parent or professional (not billable)
Student Name:                           Medicaid #:                                 Month / Year:

 Date    *Type of    Short Term       Therapeutic Activity                    Student Response to Treatment   Initials
         Contact     Goal                                                         (must be measurable)
                     Addressed (#)
                                     Gait                    Strengthening
                                     Balance                 Coordination
                                     W/C Mgmt.               Motor Planning
                                     Transfers               Ex. Program
                                     Instruction of Staff / Caregiver
                                     _______________________________

                                     Gait                    Strengthening
                                     Balance                 Coordination
                                     W/C Mgmt.               Motor Planning
                                     Transfers               Ex. Program
                                     Instruction of Staff / Caregiver
                                     _______________________________

                                     Gait                    Strengthening
                                     Balance                 Coordination
                                     W/C Mgmt.               Motor Planning
                                     Transfers               Ex. Program
                                     Instruction of Staff / Caregiver
                                     _______________________________

                                     Gait                    Strengthening
                                     Balance                 Coordination
                                     W/C Mgmt.               Motor Planning
                                     Transfers               Ex. Program
                                     Instruction of Staff / Caregiver
                                     _______________________________

                                     Gait                    Strengthening
                                     Balance                 Coordination
                                     W/C Mgmt.               Motor Planning
                                     Transfers               Ex. Program
                                     Instruction of Staff / Caregiver
                                     _______________________________

                                     Gait                    Strengthening
                                     Balance                 Coordination
                                     W/C Mgmt.               Motor Planning
                                     Transfers               Ex. Program
                                     Instruction of Staff / Caregiver
                                     _______________________________

                                     Gait                    Strengthening
                                     Balance                 Coordination
                                     W/C Mgmt.               Motor Planning
                                     Transfers               Ex. Program
                                     Instruction of Staff / Caregiver
                                     _______________________________

                                     Gait                    Strengthening
                                     Balance                 Coordination
                                     W/C Mgmt.               Motor Planning
                                     Transfers               Ex. Program
                                     Instruction of Staff / Caregiver
                                     _______________________________

                                     Gait                    Strengthening
                                     Balance                 Coordination
                                     W/C Mgmt.               Motor Planning
                                     Transfers               Ex. Program
                                     Instruction of Staff / Caregiver
                                     _______________________________



Supervising Therapist Signature /Title and Date: ____________________________________________
Therapy Assistant Signature /Title and Date: _______________________________________________
* Type of Contact: I = Individual  G =Group SA = Student Absent TA = Therapist Absent SU = Student Unavailable
                    TU= Therapist Unavailable C = Communication w/ parent or professional (not billable)
Student Name:                           Medicaid #:                                 Month / Year:

 Date    *Type of    Short Term       Therapeutic Activity                    Student Response to Treatment   Initials
         Contact     Goal                                                         (must be measurable)
                     Addressed (#)
                                     Gait                    Strengthening
                                     Balance                 Coordination
                                     W/C Mgmt.               Motor Planning
                                     Transfers               Ex. Program
                                     Instruction of Staff / Caregiver
                                     _______________________________

                                     Gait                    Strengthening
                                     Balance                 Coordination
                                     W/C Mgmt.               Motor Planning
                                     Transfers               Ex. Program
                                     Instruction of Staff / Caregiver
                                     _______________________________

                                     Gait                    Strengthening
                                     Balance                 Coordination
                                     W/C Mgmt.               Motor Planning
                                     Transfers               Ex. Program
                                     Instruction of Staff / Caregiver
                                     _______________________________

                                     Gait                    Strengthening
                                     Balance                 Coordination
                                     W/C Mgmt.               Motor Planning
                                     Transfers               Ex. Program
                                     Instruction of Staff / Caregiver
                                     _______________________________

                                     Gait                    Strengthening
                                     Balance                 Coordination
                                     W/C Mgmt.               Motor Planning
                                     Transfers               Ex. Program
                                     Instruction of Staff / Caregiver
                                     _______________________________

                                     Gait                    Strengthening
                                     Balance                 Coordination
                                     W/C Mgmt.               Motor Planning
                                     Transfers               Ex. Program
                                     Instruction of Staff / Caregiver
                                     _______________________________

                                     Gait                    Strengthening
                                     Balance                 Coordination
                                     W/C Mgmt.               Motor Planning
                                     Transfers               Ex. Program
                                     Instruction of Staff / Caregiver
                                     _______________________________

                                     Gait                    Strengthening
                                     Balance                 Coordination
                                     W/C Mgmt.               Motor Planning
                                     Transfers               Ex. Program
                                     Instruction of Staff / Caregiver
                                     _______________________________

                                     Gait                    Strengthening
                                     Balance                 Coordination
                                     W/C Mgmt.               Motor Planning
                                     Transfers               Ex. Program
                                     Instruction of Staff / Caregiver
                                     _______________________________



Supervising Therapist Signature /Title and Date: ____________________________________________
Therapy Assistant Signature /Title and Date: _______________________________________________
* Type of Contact: I = Individual  G =Group SA = Student Absent TA = Therapist Absent SU = Student Unavailable
                    TU= Therapist Unavailable C = Communication w/ parent or professional (not billable)

								
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