When documenting services for children,
A) the term "patient" or "client" should be used.
B) the Health Insurance Portability and Accountability Act does not apply.
C) the term "infant" or "child" should be used.
D) there is no need to document physical therapy services because the team writes a joint report.

Question

Quizplus · Accepted Answer

Referring to the "infant" or "child" in documentation instead of using the labels "patient" or "client" (as recommended in APTA's Defensible Documentation: Setting Specific Considerations in Documentation [2011]) makes reports more personable and fosters family participation. HIPPAA does apply for children. When there are team services, there is still a need for physical therapy documentation, which might be part of the total team's report.

When Documenting Services for Children