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Pediatric Documentation

Tailor WebPT’s documentation for pediatric patients. This article includes information on patient creation, documentation, and Medicaid requirements.

Use Habilitative Checkbox (formerly Pediatric Profile)

Create the patient following the instructions here. Be sure to check the Use Habilitative 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. For basic information on completing an initial exam, watch this video.

Subjective Tab

In the Basic Info section:

  • Some cases may require using the patient’s date of birth for the Injury/Onset Date/Change of Status date in the Basic Info section (Subjective tab).
  • If you are treating a speech patient, use the Speech Profile drop-down to select Speech. For more information on documenting for a Pediatric Speech Patient,click here.

The Medical History section contains additional diagnostic questions specific to pediatrics including special precautions. You will need to choose the Informant Providing History from the drop-down.

Objective Tab

This section is preloaded with pediatric-specific tests and measurements. If you want to customize the tests available, you can create your own examination profile using the steps outlined here. Please note that Medicaid requires the completion of an OMT.

In the Outcome Measurement Tools section, click the  Yes radio button for Pediatrics. 

You can 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.  

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 one Outcome Measurement Tool for all evaluative notes. Because of this, WebPT requires all evaluations with Medicaid insurance types to have at least one 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.


Is this documentation compliant with Medicaid?

Yes, WebPT has worked with experts to ensure that the pediatric documentation follows the guidelines outlined by Medicaid.

How do I treat pediatric patients for speech?

The pediatrics model can be combined with other specialty documentation types such as speech by using the Speech Profile drop-down in the Basic Info section of the Initial Examination. This will load pediatric-specific speech tests and measurements.

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