Transcript:
Nakia Ervin
There we go. In three, two, one. Okay, so we’re gonna start this again. So hello again, everyone. Good afternoon, my name is Nakia Ervin and I will be chatting with you today about defensible documentation. So let’s take a moment to have a little moment of honesty. So we can all be honest as clinicians, especially if you’ve done this longer than three days, documentation is typically not your favorite thing about your job. It is not what we love about our job. It’s tedious. It’s time consuming. It just tends to pile up if you don’t pay attention to it. It’s one of those things that it’s just like, ugh, I have to do this. Everything else about my job I love. I love working with the kids. I love the interventions. I love seeing growth. I love celebrating improvement and progress, but then I have to write it down. So it’s not that great, right? Everybody can clearly agree that documentation is not on your what I love about your job list. However, it’s something that we have to do.
I took a continuing ed course many, many years ago and the presenter said there are certain things in our careers that are a gotta, not necessarily a wanna. And documentation is definitely a gotta. It’s something you’ve got to do. So if you hate it or if you’re not a fan, don’t worry, relax, you are absolutely normal. However, the immutable truth is it’s required. So it’s something that we have to do. And when we do anything, we should do it well, okay? So regardless of your feelings, it’s our reality. It’s something that we have to do. And so in addition to reporting some essential data and progress about the children that we work with and the interventions that we provide, documentation actually validates the services that we provide, okay? So that’s something that makes it really important. Another thing is that it is legally required and it must be done accurately in order to avoid negative legal ramifications. And for those of you who are new to schools, those legal ramifications come in the form of lawsuits. And those are things that we want to avoid. And yes, it might not be a personal lawsuit against you, but it is a lawsuit against our LEAs and the districts that we support. So we definitely wanna avoid that as much as possible.
But the one thing that can touch you where your documentation can cause you personal and professional pain is that it can lead to fraud, okay? And the reason why that is, and I like to really just kinda tease this out because most people are like, why would it lead to fraud? Well, you are paid to do a job, especially working with info. We contract with our districts and our local educational agencies. And we promise that we’re gonna provide them a service that’s gonna support their schools and students. And every time you turn in your time sheet, you’re saying that you’ve done every aspect of that job. You’ve serviced your students, you’ve attended your meetings, you’ve done your documentation. It’s all recorded and it’s in the official documentation system.
Nakia Ervin 03:03
But if it isn’t and you’ve been paid for that time, that could constitute fraud and they could come back and take action against the company and ergo you, okay? So these are little things that good solid defensible documentation can prevent, okay?
So there are different types of documentation in school-based settings, okay? Of course, one, there is program documentation. And program documentation is documentation that relates to the IEPs or the IFSPs, for those of you who know. So individualized education programs and individualized family service plans. So those documents, when we update those on an annual basis or whatever the frequency requires, because of course, IFSPs tend to have to be updated a little more frequently because those children develop so quickly, that documentation has to be done in order to reflect how the student has grown over the course of a program year, okay? The same applies to 504s and then of course, assessments. So assessment documentation, writing your reports and anything that’s associated with your reports, that all is constituted as program documentation. Then of course, there is service documentation and that’s what we do the most because your service documentation reflects the services that we actually provide, whether that be our direct services or our indirect services like consultation and coaching. And then of course, progress reports, which are typically done quarterly or whatever the agreed upon frequency is for your student’s particular program. Okay, so let’s talk about each of these. So plan documentation. What is it to? What is it for? Why are we doing it? So it establishes the purpose and the parameters in which the students receive the services that we provide. So it’s those prescriptive services in their IEP or their 504 plan where we’re describing why the child needs this service. So this is important because it definitely reinforces why we are participating in this child’s education. So students in the United States of America are entitled to instruction, and when they say instruction, they mean a general education curriculum. Anything that’s done outside of that general education curriculum has to be documented, okay? So, and it has to be essential for that child to learn. So when we’re entering information into the plan document to establish why we’re working with that student, that helps justify legally why we are taking time away from this child participating in a general education curriculum or time with an educator to work with them, okay? So that is why it is important for this to be defensible and thorough. It also provides the goals and the objectives that define if the student is acquiring the skills that we’re setting out to work on, and if they are successfully learning in their programs because of the acquisition of these skills, as well as the interventions of whatever profession you represent.
Nakia Ervin 06:09
So we need to show that the interventions that you’re providing are effective, and documenting that in the plan document on the renewal period is what’s going to demonstrate that. So for example, if you started an IEP with a student, an initial IEP with the child, and the child was performing at 50 percent accuracy in whatever skill that you’re targeting. In the next IEP, and your goals, and your goals actually say that you’re going to get that child to 75 percent accuracy. In that next IEP or 504 document, whatever your service plan is, it should reflect that the child achieved that goal, or it should explain significantly what happened over the course of that year that didn’t allow them to achieve it, okay? And what methodologies or what strategies or what directions the team went in to adjust the child’s plan during the course of that year. Because of course, if a student is not making progress based on the goals that we have determined were essential for them to learn, then we need to take action when we’re showing that our interventions are not successful. So your plan documentation should represent that, okay?
We definitely wanted to show that they’ve achieved every goal that you’ve set out and objective. However, if it’s not, it needs to in detail describe what has changed or what has transpired during that year as to why the previous goals were not met, okay? So with service documentation, the documents, these documents, the types of interventions that we are using, so what we’re doing to work with these students, and how it supports and resolves the students’ challenges, okay? So that’s why we’re targeting such and such goals. So if we’re speech-language pathologists, we’re targeting fricatives so the child can be a more effective communicator in the classroom or throughout the educational setting. We want to show that a student participating in self-management skills is able to effectively engage and attend and participate in the classroom and actually benefit from the concepts that are being presented there, that they are available for learning. So we want to make sure that we’re documenting the types of interventions that we’re using to get that student there in our service documentation, okay? And we’ll touch on how we can effectively do that a little later.
It also, our service documentation also reports the student’s response to the interventions that we’re providing, and it shows the progress. So we’re showing that in our documentation, I provided this type of intervention where we worked on, you know, mouth position or we worked on taking deep breaths and counting from 10 to get ourselves centered and back to focus. And this is how the student responded to that intervention. This is the skill that they’re showing now. This is how they’re executing. This is how they’re performing. This is how they’re communicating. So we want to show in that documentation that the student’s response to our intervention is effective or ineffective if that’s also the case. Again, so we want to make sure that whatever we’re writing shows how they respond.
Nakia Ervin 09:21
And lastly, it also demonstrates that the prescribed services that are in that student service plan are being provided. So it is basically like your exit ticket, your golden ticket saying, you know what, it says I’m supposed to service this kid five times a month. Well, here’s the proof. Here’s the documentation. This is what we did. This is where we did it. This is why we did it. This is how we did it. So on and so forth. Done, signed, sealed, delivered, okay?
Because we know there’s a dictum as professionals in our respective disciplines. If it’s not documented, it didn’t happen. Okay. So even if you’re providing the best services in the world, if they are not documented in the official documentation system, they might as well have not existed because there’s no proof that they happened. Okay. Okay, so what makes documentation defensible? So, defensible documentation accurately, and I like to emphasize that, accurately captures the services that you provide, okay? We definitely don’t want flights of fancy. We do not want creative works of fiction. We want you to report exactly what you’re doing and exactly how the student is responding to it, okay? And how we achieve that, we one, must make sure that it’s factual. Again, it actually has to reflect what happened when you worked with this child, okay? Because the worst thing that can happen to make your documentation indefensible is if you say this child can 100% pronounce every letter in the alphabet with perfect articulation. And then the moment everyone else works with the child, he’s like, no, okay? So clearly, that’s not what’s happening, or at least it’s not even generalized if no other person can corroborate the skill that you are testing has been acquired by this child, okay? So we wanna make sure that what you’re documenting is actually what the student is able to do, or how the student is responding to the interventions and the intervention that you are actually providing, because what it can also be is a roadmap to reflect and say, these are things that didn’t work, or these are things that weren’t effective, and so these are things that we need to do to go in a different direction, or maybe we need to try something differently, okay?
And we’re gonna touch on why that aspect is important a little later as well. Defensible documentation should also be concise, okay? So when I say concise, keep the facts, okay? You wanna state the facts, you wanna kind of curb the desire to write these lovely, fluffy, anecdotal, heavy documents, okay? We don’t need to know that he’s a wonderful kid and he loves playing with butterflies and shoestrings. There’s a place for that, but it should be very, very minimal, okay? It shouldn’t take the place or the focus of effective documentation. We really just wanna know what’s going on. We love that he’s a wonderful kid, we love that he’s happy, we love that he loves to get stickers, and he gave you a great big hug when he walked into the therapy room, but in actuality, what needs to be reflected in that document is the brass tacks,
Nakia Ervin 12:22
the meat and potatoes of what happened in that service session, okay? Or in that plan. They also need to be timely. So timeliness is very important, and the reason why I stress that is because every type of documentation typically has a reporting requirement.
There’s usually some kind of deadline, timeline, or something that is governed to ensure that compliance to documentation is happening in your respective jurisdiction. And typically, those requirements come from your jurisdiction, and because they are policies in your jurisdiction, they can be actionable. So for example, in some jurisdictions, documentation or service documentation from a previous month must be in the official documentation system by the fifth of the following month, okay? So if you fail to meet those timelines, there are times when a parent, an advocate, someone else who’s representing the student can come and try and pull documentation. If it is not there, they can make accusations that services have not been provided. And then imagine what it looks like when you come up after the fact and go, oh, no, no, no, I did it. See here, here it is, right? Because then now that raises questions where is there authenticity to the documentation? Did it actually happen? Are they just, is the district just now presenting this? Because they’re trying to avoid a curve ball in a legal case. So those are the kind of things that you wanna be able to avoid. So the best way to do that, submit your documentation timely. Complete any type of task that’s associated with your treatment plans in a timely fashion or by the established timeline. For example, IEPs, the assessment window for an IEP is 60 days. Don’t drag your feet and then get to the last minute and try and hammer out an assessment report and then break a timeline because now the team is out of compliance and that can be actionable. So timeliness is super duper important. Please attend to timelines. And some great ways to avoid those pitfalls are planning ahead and setting deadlines prior to the actual deadline. But we’ll get into that a little more later as well. Another thing that is really, really important in making your documentation defensible is making sure that is in alignment with the student’s plan. Okay, so the interventions that are agreed to or the skills that are targeted in a student’s respective plan are what we are supposed to be working towards. And we also have a description of services that also indicates the type of services that we are providing. Again, all students in the U.S. are entitled to an education and anything that is outside of the course of a general education curriculum has to be documented and essential. So if we’ve agreed upon working on specific skills and if your service description says you are working on certain skills, do not have documentation that has you out of the box of that. The reason why that can become actionable is because now a parent can claim that you are taking time away from their child’s instruction, from their right to education, to work on something that might not be an issue,
Nakia Ervin 15:45
right? And the reason why it might not be an issue is because it wasn’t presented in the student’s agreed upon legally actionable plan. So if there is something that you find that the student needs to work on and you want to include that in your service plan, please call an IEP meeting or have the case manager call an IEP meeting so that you can add it to the plan and be within the compliance of that plan. Because when you go what we like to affectionately call going rogue, then that can create an actionable situation.
Because if little Jonathan starts failing in math and they start realizing, well, he’s going with the OT to work on shoe tying, but shoe tying is not in this plan. You’re taking away, you’re violating that child’s right to instruction to work on something that’s not impacting his learning. Okay. So we want to make sure that what we’re doing, what we’re documenting is in alignment with the student’s plan. Okay. Last but not least, it needs to be data driven. Okay. Data needs to be reflected in all aspects of what you document in some way, shape, or form. So some therapists approach things a little differently depending on the frequency and how you work with your students. Some therapists work on the interventions and are like, these are the interventions that we did. And they might not pull the data every single solitary session, which is fine. It’s called the test model. So like, in education, the test model is you instruct, you instruct, you instruct, and then you assess, right? So you might not be pulling quote unquote data data until you get to the point where you’re getting hard data from the assessment, but you’re pulling soft data along the way, right? So I always impress upon our providers, please pull soft data along the way, even if that is your methodology, because then you can go back and justify why you made the decisions you made in their interventions and how it directed what you did.
Okay. But essentially, data needs to be reflected. You have to be able to be able to do the same thing in your own way. So it’s not just a question of the question of the question, because when it comes down to it, if there’s a due process case where you have to defend the decisions that you made to support this child, it’s more easily reflected when the data is easy to follow. Okay. And when it’s easy to follow, it’s defensible. If you have to go in and really, really dig to try and make it all connect together, it can be actionable and it may not come out in the favor that you think. So you either have to be a really great explainer and orator, or you might suffer. Okay. And due process is already a stressful situation. So we don’t want you to even have to get there. In any event that you do, we want it to be as easy as walking the documentation. Okay. And the best thing that I can also recommend when you’re recording your data in your service documentation, record it in the parameters in which the goals and objectives are presented. The reason why I say that, because then it’s a lot easier to identify.
Nakia Ervin 18:47
So if the parameters say that the student will perform it in four out of five opportunities, then make sure that you reflect the number of opportunities in that data. Make sure that you’re documenting the percentage of accuracy or whatever those parameters are, because when it comes down to it, it’s apples to apples. But if you have to say, Oh, one day he did super great. And he was just, you know, he did really well with that task. Really well is not quantifiable. And if a parent questions how well their child is doing based on your documentation or the progress that you’re reporting, it’s going to be very difficult for you to try and find a way to quantify he did really well with the activity rather than saying he did, he was able to demonstrate the skill on three out of five opportunities.
Okay. All right. So here are some really easy documentation pitfalls. Okay, there are several that are super avoidable. One, missing established documentation timelines. Timelines are the responsibility of the local educational agency, no matter what the concern is. I’m sure many of you, especially if you’ve been in schools for a really long time, have experienced things where setting meetings might be a challenge because the parents won’t agree on a day or the follow through of the team to make sure that things get on the calendar. At the end of the day, if we were to go to court for that, we are responsible as the LEA.
And we are agents of the LEA because even though we’re contracting with our districts and the other educational entities that we work with, we are an agent of that entity. So it is actionable against the LEA when we don’t adhere to timelines because we’re supposed to know better. Again, we’re the subject matter experts, quote unquote, for education. The parents are not responsible for us adhering the timelines. And that’s why a lot of times schools and districts are ruled against when those types of things happen, when those timeline infractions happen because they’ll say, well, the school district knows that they have to do their due diligence. So even if the parent is on the other side, the parent is not the only member of the IEP team. And while it is the expectation that they want everyone to participate, the fiduciary responsibility falls on the local educational agency to ensure that that student is receiving what they’re entitled to. So you can’t let the parent, and at the end of the day, you can’t let the parents stall out. Most districts have policies that support that, like a three opportunity or a three attempt opportunity reporting task, like when you’re, or notification requirement. So if you’ve tried to notify the parents three times and they didn’t participate, you proceed, and then you can come back and amend if necessary. But if you don’t, just be very mindful to plan ahead and make sure that you don’t end up in some timeline pitfalls, okay?
That also applies to you submitting documentation and all that on timelines, okay? Plan ahead, make sure that you are planning ahead of the deadline so that your stuff is submitted by the deadline, okay?
Nakia Ervin 21:53
Another thing, not placing your documentation in the official documentation system. This is one of the biggest challenges and the easiest to avoid because it’s as simple as putting it where it belongs. Most districts have electronic documentation systems, and that is the official documentation system for that district. That is where your documentation belongs.
That is where your service plan belong. That is where your notes belong. So please, even if you keep your notes and documentations in these beautifully organized and crafted notebooks that have all these beautifully colored tabs, that’s all well and good. But if it does not make it into that official documentation system, that is a problem. So please make a habit of trying to get everything in either the same day, point of service is the best. So if you have the opportunity to do point of service documentation where you’re documenting while you’re working with the student, and it is a, you know, it can be a challenge depending on the children you’re working with or whatever you’re doing, but definitely try to get it in by the same day. Second, a slightly different second place is the same week, okay? But definitely do not make a habit of holding onto your documentation until the end of the month or until the reporting deadline and then trying to go back and push all that in the system. What it breeds is procrastination and procrastination breeds that it never makes it into the official documentation system. And now we’re out of compliance. Now it’s a violation, okay? So we definitely wanna make sure that you’re getting it into the official documentation system as regularly as possibly. Again, first place, always point of service, slightly second place, first place, same day and distant second, same week, okay? Just kind of make that your mindset. Lastly, mistaking anecdotal information for data. Again, as I was talking about on the previous slide, saying things like, oh, he did great, he did well. That’s wonderful, okay, wonderful. I love that you’re a cheerleader and you’re supporting your student. However, great and well are not quantifiable. We need to make sure that you are actually reporting the data that demonstrates skill acquisition because when you’re on that stand, if you happen to end up in due process because of something like this, it’s very, very difficult to justify he did great, okay? Or he’s a wonderful kid, or he was so happy when he came to session. Oh, that’s wonderful. However, comma, I would minimize the anecdotes, maximize the data and the accuracy of reporting of what you actually did and only report that kind of information. Oh, he came to session and he was upset if it had an impact on how he did, okay? So if you have a student that’s usually slow to engage and then after eight sessions of him slugging through it or not engaging or not participating in session as effectively as you would like them to, that he skipped to OT one day, document that.
Nakia Ervin 25:02
Cause you can say, oh, and cause that can justify why he started showing improvement. Like, oh, this particular day, for some reason, he was happy to come with me. There was no fight. He didn’t kick and scream all the way down the hallway. So that, like a small blurb about that, and then if he subsequently performed well, that can also say his attitude, his mood was better.
So he performed better. So those are things that will support the data that you’re gathering. So your anecdotes should support your data and they shouldn’t replace your data. Hopefully that makes sense to everybody. Okay, so some tenets of defensible documentation. So number one, defensible documentation should be easily understood by anyone who works with or supports your student, okay? So moms, dads, parents, Indian chiefs, anyone, okay, who works with this student, should be able to pick up your documentation and understand what you’re saying.
I try to encourage people to avoid jargon, okay? Jargon is great. It shows how brilliant you are as a clinician, but at the end of the day, not everyone who is reading your report is an SLP or an OT or a PT or an element OP, okay? We wanna make sure that whoever picks it up can read it and understand exactly what you’re working on. So layman terms are important. Now, if it’s necessary to use a clinical term, please take a moment or put in parentheses what that term means. So whoever’s reading it, a layman can say, oh, okay, that’s what that means. So you’ve now taught them something, but they still understand what you’re doing, okay?
Defensive documentation should also clearly demonstrate what services were provided, why the interventions were used and how the student responded to them, okay? So what I like to affectionately call who, what, when, where, why, how, okay? And we’re gonna talk about that a little later and I’m gonna give you a little tool that’ll help you with that. So the reason why that’s important is because you wanna be able to easily understand and it can be easily justified why you did what you did, right? So for example, I had some wonderful young new grad OTs who were like, oh, I started my session with coloring. All of their documentation was student colored for 15 minutes, student blah, blah, blah, blah, blah. And I said, OK, so the student colored for 15 minutes. But why? Oh, because we always start our session with coloring. No, there needs to be a purpose for that intervention because they can color in the classroom, OK? They don’t need a specialist to color. Now, if you’re saying you’re coloring to work on hand strengthening, you’re coloring to work on spatial awareness so that you can transition to spatial awareness as it pertains to writing so that they can write inside of ruled lines, that needs to be explained. Because otherwise, people think that all you’re doing is pulling this child away from instruction and a qualified teacher to color when they can color in the classroom, OK? Or if you’re using coloring to work on writing grasp or posture or what have you, the end of the day, it needs to be explained, OK?
Nakia Ervin 28:11
And it needs to say why you use that intervention because you could have worked on it another different way. You could have had them use push pins or what have you. But you want to explain why so they understand why you’re doing what you’re doing so it doesn’t look like it’s something off base or even worse, rogue, OK? And then you also want to talk about how the student responded. Did they do well with it? Is it helpful? Because if for whatever reason, you lose this student or the student moves to another school or what have you, the next professional needs to pick up and see what some of your interventions were and if they worked or not so that they don’t have to reinvent the wheel or try to retest things that weren’t effective, OK?
And that’s what brings me to my next bullet point. Divisible documentation should be easily relatable and transferable from one servicing professional to the next, OK? So the next OT, the next FLP, the next PT, the next teacher, whoever, they should be able to pick up your documentation and know everything that has been worked on with this student and why it was done and how the student responded to it and how they’re doing with their progress towards their skill acquisition, OK?
So it should be easily, easily picked up by the next professional who is working with them, OK? And defensible documentation should demonstrate compliance to all regulatory guidelines established by the laws that govern whatever services you are providing. So if it requires that documents, for example, for IEPs, right, certain services are indicated on the IEP to be provided in certain locations, inside of Gen Ed or outside of Gen Ed, OK? That needs to be included in your documentation because in order to ensure that you’re compliant to the service, how the services have been agreed to, it should be reflected in your documentation where you work with that student, OK?
Now, for some of our documentation system, there are a lot of dropdowns and click buttons and things that allow these things to be a little easier. So like most of them will allow you to do a timestamp so you’re not entering in the time to justify the duration of your session or you might be able to click outside Gen Ed on a button, but you want to make sure it’s reflected. And I usually encourage people to actually include that in your documentation, even in like the intro narrative. And we’ll talk about that when I provide an example. OK. So, some best practices. With plan documentation, ensure that your documentation directly explains the deficits and disabilities that your services will support and justifies the necessity of your service. So, as we discussed earlier, make sure that your plan documentation, your IEP entries, your present level of performance, all of that explains why this child needs to work on whatever said skill is being targeted and why they would need your service, okay? So, not necessarily like in the present levels that they need OT to work on this, but it should definitely set it up to tee up the support of the service that’s indicated in the service section below.
Nakia Ervin 31:22
So, it’s like this student needs intensive intervention to work on handwriting or hand skills or a bilateral coordination or what have you because in order to effectively participate in learning activities. And then when they see OT services in the service section and your service description says to work on bi-manual coordination skills, it’s reflected in the plan, okay? So, it’s easy. It’s an easy dot to dot, draw a line and connect the dot circumstance. We want it to be as simple as possible because the things that are simply explained are the most defensible, okay?
One include data points in your reporting that will easily provide comparative data. So, it should show like in your previous year plan, if it shows that it was at 50%, you want to report that same information in the renewed plan, in the updated plan, in the annual review. You want to show in that present level and honestly, I even encourage make the comparative. In the previous IEP, he was performing this skill at 33% and is presently performing the skill at 49% or 78% or 80% or has mastered this goal at blah blah blah percent accuracy. You want to make sure that it is clearly reflecting progress, okay?
And the reason why we want to clearly reflect progress is because lack of progress is one of the chief reasons as to why service plans are taken to due process, okay? We also want to work on, we want to include whether mastery of skill acquisition is generalized, okay? So, we don’t want to see that during OT sessions, he demonstrates the said skill or that you’re reporting in the plan, in the present level, something that you have only been able to see and corroborate, okay? Because a lot of things can happen in one-on-one, but again, the performance environment is in that classroom where the child is supposed to typically perform. So, if we pull them out and they’re working on a skill and they’re doing fantastic with it and you push them back into the classroom and they act like they’ve never seen a pencil before or they act like they’ve never worked on any articulation and they’re still saying amaryllis instead of amaryllis, okay? That means that the skill is not mastered, okay?
It’s not mastered unless it’s generalized. How is it generalized? They perform it everywhere they go, no matter who’s around. And a teacher, excuse me, should be able to corroborate that they have seen performance of that skill in the classroom with them, okay? So, please avoid reporting mastery unless you are sure the skill is generalized, okay? In the service documentation, your service documentation should also directly align with the aspect of the student’s plan that support your service description. Again, do not go rogue, okay? Whatever is reflected in the service plan, whatever was agreed upon and signed off on by the parents, that is what we should be providing, okay?
And so I’m going to take a moment to actually show you guys a tool that will be helpful in this capacity.
Nakia Ervin 35:01
Thank you. So, you all should be able to see a tool that says who, what, when, where, why, how, okay? Does everybody see that? Is that on the screen? We’re good. All right. Cool beans. Thanks for the thumbs up guys.
Okay. So the who, what, when, where, why, how guide is a great way to look at school based documentation and what it walks you through are all of the tenants. I just discussed making sure that you’re encompassing in your documentation, all things that are relevant. So this is actually going to be based more so on service documentation.
And so with service documentation, you want to make sure that you’re capturing all the key things that are required of a student service plan. So one, when, okay. So the things that justify that services were provided. When was it provided? What date? What time? Okay. And those should be things that should be easily corroborated by a principal going and pulling up a camera if necessary. Okay. They can say, Oh, you know, the, you know, Larissa, Miss Larissa took him to OT and there she is walking down the hall. She said the service session was from 10am to 1030. There they are leaving the classroom, walking down the hall into the OT room. Very easily corroborated.
Okay. So when did it happen? When, when did you take them? What date? What time? Who? The child. Okay. So if your documentation system doesn’t already because most documentation systems now easy IEP and quite a few of them power schools and the like, actually have individualized profiles for each kid. So when you’re logging them, their profile comes up, you pick their note, it pops up. So usually those are automatically included in your note. But it’s also good to restate the student’s name as well. So it also helps you defensively say, I knew exactly who I was working with.
See how I documented his name multiple times in my note. Right. And the one thing I caution with that is if, because there are people who brilliantly use templates when they’re documenting, especially if they’ve done like a group session and everybody’s working on the same skill. Be very, very careful about making sure that the names align with the respective student. Be very, very careful. Templates are great things until you don’t change a name.
Okay. And now you’ve turned your brilliant use of a template into an actionable circumstance. Okay. So we want to avoid that like the plate. Please double check your name. Please put it in a Word document. And if you’re changing Robbie to David, put find all Robbie and change all to David. Okay. But just make sure you reread proofread before you submit. Okay. Where of course you want to indicate where you worked with that student inside the classroom or outside of classroom. I also like to caveat that because actually inside gen ed and outside gen ed do not technically mean the physical location. It means, did you push into typically occurring instruction or did you pull them away from instruction per IDA? That is what that just what that distinction means. So you can still work with the child in the exact same classroom where the teacher is.
Nakia Ervin 38:19
But if the rest of the class is working on math and you pull them to the back table to work on speech related goals that have nothing to do with math. That’s technically a pull out session. You pull that child away from instruction. Okay. You pull them away from gen ed. So you want to make sure that you’re indicating where you work from with them, especially if it’s indicated in their service plan that they’re supposed to receive services in those distinct locations.
Okay. What? What did you do? What was your intervention? What was the activity? What did you work on? Very, very basic. Why? Why did you do what? Okay. I did what? Because of why? And how? The most important. How did the student perform? How did they do? How did they respond to the intervention? What was their performance? Okay. So you want to make sure this is the key part where you’re reporting the data and all that other fun stuff. So we were to look at a service plan. So for example, like an IEP. And the IEP goal was that Jane will allegedly write 100% of capital letters with the use of appropriate stroke order on four out of five opportunities across three recording sessions. Okay. Service note would look something like 1113. Jane participated in a handwriting skills group with three other students in the OT room, which shows she was pulled out. Jane participated or Jane practiced directional line segments to increase her visual motor control of the writing utensil for legible fluid writing. She subsequently copied cap and letters from a model and was able to write 21 of the 26 letters or 81% with appropriate formation and stroke order.
So did I answer what the goal had indicated? Yes, we are working on the writing. We did some activities to build up to the writing such as making, you know, writing or creating those directional strokes to increase our visual motor control. And we actually worked on the skill that we’re targeting and we reported data on it, okay? So we wanna make sure that we’re showing what we’re doing, why we’re doing it, how we did it and how they performed. Okay, all right. So I think you guys are getting this. So we are going to take a little test. All right, scenario time. So what we’re gonna do, I’m gonna read the scenario and you are going to write your response in the chat. All right, so let’s walk through a service note. So Joshua receives counseling services from the social worker to address his emotional regulation and response to stressful situations. The goal that this service supports is when given a role play scenario of a stressful event, Joshua will demonstrate or describe a learned coping strategy on four out of five opportunities across three consecutive sessions. So first note, Joshua had a great session today. He worked on choosing fun activities that he can do to celebrate his completion of not preferred tests. He shared that he really likes going to science class and has two new friends.
Nakia Ervin 41:38
Option B, Joshua participated in an emotional regulation session in the counseling office. He reviewed situational scenario flashcards and discussed how that scenario would make him feel, then subsequently had to provide an effective coping strategy. Joshua was able to describe an effective strategy on three out of five trials.
Or option C, Joshua participated in a counseling session today to work on his emotional regulation skills. He discussed how his class makes him feel and what people in his class make him feel that way. When asked about coping strategies, he shared that deep breath helped him calm down. So if, which one, if you had to write this, which one would you find to be the most defensible? Okay, I’m seeing some Bs. Bs, Bs, Bs, Bs, Bs, Bs, okay. Well, let’s see. The answer is B, excellent job. So, why? It contains all the pertinent information to capture the session, who, what, when, where, why, and how. And it contains measurable data, ta-da. All right, that one’s kind of easy. Throw you guys a curve ball. So, IEP present level for fine motor performance. Joshua has been doing very well with his fine motor skills. He has been working on his fine motor skills in the classroom and with the occupational therapist. He really enjoyed going to occupational therapy services and always returns to class with a sticker. He is making good progress and will continue to work on these skills.
All right, so, is this defensible or due process, Foner? I love it, nope. Definitely, definitely. It is total due process, Foner. Okay, no information about the student skills or abilities and it does not justify any services that he’s receiving. I love that they included that occupational therapy services are happening. However, it doesn’t say why, okay? And it said, oh, we’ve got to work on these skills. What skills? There are a lot of fine motor skills. There are a lot of things that could be warranted for this student to improve on. And none of them are indicated. And again, it is primarily anecdotal. We do not want to mistake anecdotes for data. That is easy due process, Foner, okay?
And fun fact, E.T.R. Hollywood Story, that is a mild edit from something that was actually placed in an IEP. I know, scary, right? All right, so in conclusion, defensible documentation is essential to what we do, okay? It establishes the purpose and the parameters of which a student receives their prescribed services and support, it justifies why we’re there, it justifies why we’re working with them, it provides the goals and objectives that determine if the child is learning and if they’re acquiring the skills that they need to be effective learners. And it also establishes that our participation in their learning is essential to them learning, that what we’re doing is effective, that it’s supporting them, that it’s making them better students, okay?
Nakia Ervin 44:58
It also documents the types of interventions that we are trying and if it is actually benefiting the reduction of deficits. So we wanna make sure that that is included, we wanna show that what we’re doing actually matters and it’s not a waste of time and that the child needs to be with us so that they can be better performers in the classroom. It also reports how the student is doing, how they’re progressing and it even demonstrates that the services that they are entitled to are being provided, okay? So we need to make sure that our defensible documentation is factual, okay?
Just the facts that they are concise, don’t overdo the anecdotes and only write them if they support the data that you’re collecting and the interventions that you’re providing, make sure you turn them in on time and not only on time in the official documentation system, okay? We wanna make sure that they’re data driven so it’s easy to walk the documentation to see how the student is progressing and the corroboration of that information is easily reflected by the student’s performance and the generalization of the skills that we’re working on and most importantly, everything that we do, everything that we write and document needs to be in alignment with the student’s plan, okay? So our defensible documentation assures that anyone who works with that student understands the purpose and the outcomes of our services. That is so important. They need to know why the OT, the SLP, the PET, the LCSW, the whomever, they need to know why you’re involved and they need to see that what you’re doing is essential to this child’s learning. It also shows that we are compliant to all of the regulatory guidelines that govern what we do, whether that be IDEA, the Rehab Act of 1974, whatever. We need to make sure that we’re reflecting to even the state guidelines that require us or the district guidelines that require us to report in a certain way. We wanna show that we’re accommodating and that we are compliant to that, okay?
And lastly, it helps us avoid unnecessary legal issues. We don’t wanna end up in due process. It’s timely, it’s boring, it’s stressful. We wanna avoid it, okay? We also don’t wanna end up with accusations of fraud. We don’t wanna end up with things that can besmirch our hard-earned professional reputations. We wanna make sure that everything we do is above board, it’s pristine, and it’s effectively reported. Those are the things that will keep you out of those legal pitfalls, all right?
And with that being said, it’s been awesome, so I’m gonna stop sharing. And would love to entertain any questions that you have. If anyone has any issues they would like to share, does anything look like something that you’ve experienced or seen or heard someone talk about? Go for it. My only question is, do we get a copy of your presentation? Because it was brilliant, and I would like the guide. Please, and thank you. Absolutely, if you drop your name or your email address in the chat, I will make sure that after this session to forge you a copy of not only the presentation, but the who, what, where, when, how guide.
Nakia Ervin 48:23
Thank you. You’re so welcome. All right. Well, if everybody’s good, please go, but yep, definitely put your email in the chat, and I will definitely pull those and get that over to you now. But otherwise, if everybody’s good, and if anyone doesn’t have any questions or what have you, definitely it has been a blast hanging out with you guys this afternoon.
I am going to give you back your afternoon slash evening if you’re on my side of the world, because I’m on the East Coast, so the sun is going down, it’s getting dark. So at any rate, I’m going to give you all back your day. Thank you so much for joining us, and we look forward to seeing you in our next TheraChat. Wonderful, thanks so much. This is really great. You’re welcome.
