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Following completion of this chapter, the reader will be able to:

  • Compare and contrast pediatric and adult documentation.

  • Explain what information should be included in a treatment plan for a child.

  • List examples of behaviors/activities that should be assessed and documented in pediatrics.

  • Describe the concept of rehabilitation potential.

  • Discuss the role of the problem list in the initial examination.

  • Explain the difference between rehabilitation potential and prognosis.


Documentation and payment for physical therapy services when working with the pediatric population present some unique challenges. This section will address the nuances of documentation, billing, and payment issues in the context of documentation specific to pediatric physical therapy. However, the basic contextual guidelines are applicable to the adult population as well.


Many of the major categories for examination of the pediatric patient are the same as for the adult patient. In general, physical therapists (PTs) must examine range of motion (ROM), muscle tone, muscle performance/strength, sensation, posture, and function regardless of whether the child has a musculoskeletal or neurologic/neuromuscular pathology. However, the focus and content of each of these categories are unique for the child who has a neurologic impairment. In particular, young children require increased emphasis on assessment of their developmental motor skills. This section will focus primarily on conducting and documenting the content for a developmental evaluation of an infant or young child. Pediatric clients with specific diagnoses such as spina bifida warrant a more directed examination. However, the major categories described in this chapter will serve the PT well for the general pediatric population.

During the initial examination and evaluation, recording by video recording or other electronic recording can be beneficial to both the PT and the child’s parent or guardian. For the PT, reviewing the recording may allow examination of the child’s movement at a pace more conducive to reflective observation. For the parent or guardian, the video recording or other recording may be a helpful reminder of the progress a child has made, which may be difficult to appreciate otherwise. Before recording a session, the therapist should obtain express written permission from the parent or legal guardian by means of a consent form. From a risk management perspective, the video recording becomes a part of the medical record and must be afforded the same confidentiality as dictated by the Health Insurance Portability and Accountability Act (HIPAA). Consult with a risk manager or attorney to ensure HIPAA compliance.


As with any patient, the history should be the first assessment (see Figure 6-1). The most efficient way to obtain a history is with a form developed specifically for the parent/caregiver or legal guardian to complete prior to the first session. The PT can then use the information to obtain clarification during the initial session. If ...

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