Assessment - Refers to the process of determining the need, nature, frequency and duration of treatment; deciding the needed coordination with others involved, and documenting these activities. 

Evaluation - Refers to the process of determining the need, nature, frequency and duration of treatment; deciding the needed coordination with others involved; and documenting these activities.  The evaluation addresses the varying degrees of developmental delay, neurological deficits, and/or neuromuscular disorders:

• Sensory-motor skills such as sensory awareness, sensory processing, and perceptual skills
• Neuromuscular functioning such as range of motion, muscle tone, and endurance as related to daily living skills, school/work activities, play and leisure skills, and vocational skills
• Motor skills, especially fine motor coordination/dexterity, visual-motor integration, and oral-motor control
• Cognitive components such as arousal, attention span, sequencing, problem-solving, and generalization of learning
• Psychosocial/psychological components such as interest, self-concept, social conduct, self-expression, time management, and self-control
  • When appropriate, standardized tests should be used.  Standardized tests are those whose scores are based on accompanying normative data, which may reflect age ranges, sex, ethnic groups, geographic regions, and socio-economic status.  If standardized tests are not available or appropriate, the results shall be expressed in a descriptive report.

Individual Treatment - Includes the provision of intervention activities, procedures, and environmental modifications necessary to implement the goals and objectives of the IEP and the occupational therapy intervention plan.

Direct Therapy - In direct therapy, the occupational therapist has frequent contact with the student to help the student effectively meet demands (self-care, physical, and social, emotional, academic) within current and anticipated educational environments.

Monitoring - (Reimbursable as a treatment service for the time of the therapist only.)  - In monitoring, the occupational therapist develops the intervention plan to enhance IEP goals but instructs others (teachers, aides, paraprofessionals, and volunteers, parents) to carry out the procedures.  The selection of monitoring interventions should be based on consideration of both the health and safety of the student, and the appropriate procedural precautions.

Case Consultation - Reimbursable as a treatment service for the time of the therapist only and must pertain specifically and completely to an individual student.)  - The purpose is to develop the most effective educational environment for the child with special needs.  This service is frequently provided when a child shifts from a self-contained special education classroom to a regular classroom with resource room help.  Case consultation might be used to alter the style of presenting materials, to develop remediation materials for the child to use in the classroom or to adjust the demands for specific required tasks.

Billable Occupational Therapy Service Procedures 
Occupational therapy evaluation
Occupational therapy:  Individual treatment - one therapist to one student
Occupational therapy:  Group treatment - one therapist to five or fewer students

Treatment Plan Requirements  - An assessment and treatment plan are required annually.  The treatment plan must be based on an evaluation by an occupational therapist.  Further, the treatment plan must indicate goals/objectives and level of service (type and frequency of service). 

A progress note is required approximately every six months or at a reasonable interval to document the student's progress and the continuing need for service. Quarterly progress reporting in IEP Plus is acceptable when dated and signed by the provider.

Indicate where the student is in relation to the treatment plan goals. Quarterly progress reporting in IEP Plus is acceptable when dated and signed-up by the provider.

Indicate if the treatment plan requires changes in the goals and/or objectives and Indicate if the type or frequency of the treatment requires modification.

Authorized Personnel  - Occupational therapy services, when provided by the State of Delaware, licensed occupational therapist or a certified occupational therapist associate (COTA) under the supervision of a State of Delaware licensed occupational therapist.

Occupational Therapists should send the local cost recovery specialist a list of the Certified Occupational Therapy Assistants they are supervising at the beginning of each school year.

At a minimum, the records must contain the following on each client for any related service:

• Full assessment(s) in the appropriate discipline area(s) with pertinent documentation such as tests, evaluations, and diagnosis (updated at least every 3 years), and an annual reassessment documented in a written format including narrative information summarizing the child's status and the continuing need for treatment.
• A treatment plan  (IEP) prepared by the respective therapist(s) that describes the goals/objectives and level of service(s) (i.e., type and frequency of service) needed. The treatment plan is required annually and must be signed by the Occupational Therapist.
• A progress note is required approximately every six months or at a reasonable interval to document the student's progress and the continuing need for service. Quarterly progress reporting in IEP Plus is acceptable when dated and signed by the provider. A progress note should:
  • Indicate where the student is in relation to the treatment plan goals
  • Indicate if the treatment plan requires changes in the goals and/or objectives and
  • Indicate if the type or frequency of the treatment requires modification.
• Each occurrence of the student's service, including the date (three-point), type, length, and scope of professional services provided.
• Any significant contacts made in relation to the student.
• All records must contain the full signature of the professional providing the services and/or supervision.