Early Intervention	School Age	Page 1 of 2
School Name:
Student’s Name:	Date of Birth:	PA Secure ID	Service month/year:
Provider’s Name:	Title:	Provider’s Signature:	Date:
Diagnosis/Symptoms:

Service	Treatment	Progress (Refer to keys below and on page 2 for an explanation on progress indicators and treatment codes)
Date	Start Time	End Time	Total Time	Service Type

Treatment Key	Individual or Group	Progress Indicator Key	Daily Progress Note

Service Type
Progress Indicator Key
D- Direct Session

DM- Direct Session: Make-up Session
MN- Maintaining

RG- Regressing

PR- Progressing	MS- Mastering

IN- Inconsistent

Supervisor’s Name:
Supervisor’s Signature:
Date:

Treatment Key:	Page 2 of 2

1	Direct	Assistive Technology: Access to Device	26	Direct	Positioning: Postural Alignment
2	Direct	Assistive Technology: Student Training	27	Direct	Posture and Body Mechanics
3	Direct	Balance Training	28	Direct	Pulmonary Support
4	Direct	Equipment: Splint / Orthotic / Prosthetic check	29	Direct	Relaxation / Facilitation Techniques
5	Direct	Equipment: Splint / Orthotic / Prosthetic training	30	Direct	Therapeutic Exercise: Coordination Activities
6	Direct	Equipment: Student Training	31	Direct	Therapeutic Exercise: Endurance Training
8	Direct	Functional Mobility: Community	32	Direct	Therapeutic Exercise: Functional Range of Motion
9	Direct	Functional Mobility: Indoor - Level Surfaces	33	Direct	Therapeutic Exercise: Muscle Strengthening
10	Direct	Functional Mobility: Indoor - Uneven Surfaces	34	Direct	Therapeutic Exercise: Stretching
11	Direct	Functional Mobility: Outdoor - Varying Terrain
12	Direct	Functional Mobility: Outdoor - Level Surfaces
13	Direct	Functional Mobility: Transfer Training
14	Direct	Functional Mobility: Transition Training
15	Direct	Functional Mobility: Transportation
16	Direct	Functional Mobility: Wheelchair
17	Direct	Functional Mobility: Stairs
18	Direct	Gait / Ambulation Training
19	Direct	Neuromuscular Development: Head Control
20	Direct	Neuromuscular Development: Lower Extremity
21	Direct	Neuromuscular Development: Trunk Control
22	Direct	Neuromuscular Development: Upper Extremity
23	Direct	Positioning: Adaptive Seating
24	Direct	Positioning: Adaptive Standing
25	Direct	Positioning: Alternate Device

Physical Therapy Services Log

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© 2013 Leader Services [PA0313]

Physical Therapy Services Log

Leader Services

2013-03-05

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Leader Services

Leader Services