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Documentation and reimbursement for physical therapy services when working with the pediatric population present some unique challenges. This section will address the nuances of documentation, billing, and reimbursement 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 must examine range of motion (ROM), muscle tone, muscle performance/strength, sensation, posture, and function regardless of whether the child has a musculoskeletal or neurological/neuromuscular pathology. However, the focus and content of each of these categories is unique for the child who has a neurological 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 physical therapist well for the general pediatric population.

During the initial examination and evaluation, recording by videotaping/CD or digital recording can be beneficial both to the physical therapist as well as to the child's parent or guardian. For the therapist, 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 videotape/CD/digital 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 caregiver. From a risk management perspective, the videotape becomes a part of the medical record and must be afforded the same confidentiality as dictated by HIPAA.


As with any patient/client, the history should be the first assessment. 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 therapist can then use the information to obtain clarification during initial session. If there is a medical record available, the information included could be useful and may indicate information that might otherwise be difficult to obtain, such as whether there is any history of maternal drug or alcohol abuse. However, when a medical record is not available, it may not be advisable to question a parent about this history because of the degree of parental guilt that will be associated with the questions. Although the question is included in the history prototype form included for reference, the information in the history is the discretion of the facility (see Table 10–1).

Table 10–1 Pediatric History



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