Orthosis Fabrication (OF) Documentation
The Orthosis Fabrication note type allows therapists to document and bill for splints, taping, and other orthosis fabrications. In this article, we’ll review how to document with an Orthosis Fabrication note type in the WebPT EMR.
Create a New Case
The first step of documenting an Orthosis Fabrication is to create a new case. Orthosis Fabrication notes work differently than Initial Examinations, especially when considering how data carries forward into Daily Notes, so the Orthosis Fabrication note type will not be available in cases with a finalized Initial Examination.
Schedule the Appointment
After the case is created, the next step is to schedule the patient’s Orthosis Fabrication Appointment. When scheduling the patient’s appointment, be sure to select the newly created case, and the Orthosis Fabrication appointment type.
Document the Visit
The Orthosis Fabrication note type functions similarly to an Initial Examination. Here are the differences to consider when documenting an Orthosis Fabrication visit:
In the Basic Info section of the Subjective Tab, select an Orthosis Fabrication Profile. Select multiple profiles by holding down the CTRL button on your keyboard and clicking on all applicable profiles. The profiles you select will determine which fields are available in the Objective Tab.
The Orthosis Fabrication Profile(s) you select will be automatically added to the Objective Tab. For example, if you select a Wrist/Hand profile, the fields on the Objective Tab will request information specifically about the Wrist/Hand, and will follow the same logic for the upper and lower extremity Orthosis Fabrication Profiles.
|Objective Tab Section||Profile Specific Fields|
|Inspection||Girth for given upper/lower extremity|
|Range of Motion||Range of Motion for given upper/lower extremity|
|Strength||Gross muscle test and stability tests for given upper/lower extremity|
Semmes Weinstein (SWM) test for the given upper/lower extremity
The Orthosis Fabrication Billing Tab is refined to feature only the most relevant CPT codes. You’ll find Untimed Codes such as evaluation codes, as well as sections containing codes about fitting and fabrication orthoses. Any codes not populated on the Billing Tab can be added using the Custom CPT code feature.
Document Follow-up Visits
If the patient returns for a follow-up visit related to their Orthosis Fabrication, use an Orthosis Fabrication Daily Note. These notes work similarly to Orthosis Fabrications, but you’ll find that the billing portion of the note has moved to the Objective Tab, much like normal Daily Notes.
To open an Orthosis Fabrication Daily Note:
- Navigate to the desired patient’s chart.
- Select the case that was created for the Orthosis Fabrication.
- Select Orthosis Fabrication Daily Note from the Patient Record Actions dropdown menu.
You’re ready to start documenting Orthosis Fabrications in the WebPT EMR! To learn more about other documentation note types in the WebPT EMR, click here.