Pediatric Speech Documentation

Learn how to complete speech documentation for a pediatric patient. This article includes information on patient creation, documentation, and Medicaid requirements.

Pediatric Profile Checkbox

Create the patient following the instructions here. Be sure to check the Pediatrics Profile checkbox in the Patient Info section to automatically populate the Initial Examination with pediatric-specific tests and billing codes.                                                                                                                                                     

Initial Examination

In the patient records section of the patient chart, use the play button to begin the Initial Examination. 

Subjective Tab

In the Basic Info section, select Speech from the Speech Profile drop-down. This will toggle the documentation to suit the needs of a speech therapist, blending the Pediatric and Speech profiles.                                                                                    

The Medical History section will contain additional speech-specific diagnostic questions and expanded Medical History options, including Cleft Palate, Previous MBS, etc.

Objective Tab

This tab is preloaded with speech-specific tests and measurements. To access additional tests, let’s review how to add Speech Evaluations to the Outcome Measurement Tools section. Additionally, If you want to customize the tests and measurements available, you can create your own examination profile using the steps outlined here. Please note that Medicaid requires the completion of an OMT.

  1. In the Add Tests search bar type speech.
  2. Select Speech Evaluation (OMT-Pediatrics)
  3. Use the Play button to add.
  4. Next, in the Outcome Measurement Tools section, click the Yes radio button for Pediatrics. 
  5. Then select the Yes radio button for Speech Evaluation and choose the desired OMT. 
  6. Tip: use the Custom Outcome Measurement section to include an OMT that we have not yet added to WebPT. Remember to upload the completed test into eDoc.  
  7. If you want to include additional custom tests and measurements you can use the Additional Comments box in the appropriate section.        

Medicaid Requirements

Medicaid requires completion of one Outcome Measurement Tool for all evaluative notes. Because of this, WebPT requires all evaluations with Medicaid insurance types to have at least Outcomes test score. If you choose not to do an OMT, you must enter N/A into the score box in the ‘Custom Outcome Measurement’ section in order to finalize the note.

Assessment Tab

Because goal durations may exceed our preset timeframes, you may find it beneficial to select the custom option and input the expected duration. This will carry forward on for each note. 

Plan Tab

You must set a Frequency and Duration for this patient, regardless of insurance type. Because many Medicaid certification dates can last up to 6 months, you will need to use the Custom option from the duration dropdown. This information will populate in future notes for this patient. 

If you want to include custom information in the Treatment to be provided section, use the Other checkbox in the Specialties section.                                                           

Billing Tab

Select the appropriate billing codes. When complete, Preview and Finalize.

Continuing Treatment

Subsequent treatment documentation can be completed following WebPT Documentation practices. Use daily notes for standard visit documentation. Use progress notes every tenth visit or if the patient presents with a significant change in symptoms. Finally, use the appropriate discharge note to complete patient treatment.