Which Fields Carry Forward (SOAP 1.0, Non-Medicare)

Let's discuss which fields carry forward from evaluative note types (starting with the Initial Evaluation) to the subsequent daily notes for Non-Medicare insurance types in SOAP 1.0 documentation.

Daily Note

The following fields populate subsequent daily note when entered in the finalized Initial Evaluation.

Subjective Tab

Diagnosis
Treatment Diagnosis
Treatment Side
Specific Physician Orders
Date of Initial Examination
Injury/Onset Date/Change of Status Date
Movement-Based Spinal Assessment Questionnaire
Work: Mechanical Stresses
Leisure: Mechanical Stresses
Functional Disability From Present Episode
Functional Disability Score
Present Symptoms
Commenced as Result of
Symptoms at Onset
Constant Symptoms
Intermittent Symptoms
Bladder
Current Complaints / Gains
Prior Level of Function
Current Functional Limitations
Pain
Medical History

Objective Tab

Place of service
Plan of Care
Untimed Codes
Direct Timed Codes

Assessment

Rehab Potential
Goal List

Non-Medicare - Progress Note/Re-examination

The following fields populate subsequent evaluative when entered in the finalized Initial Evaluation and daily notes.

Subjective Tab

Diagnosis
Treatment Diagnosis
Treatment Side
Specific Physician Orders
Date of Initial Examination
Injury/Onset Date/Change of Status Date
Movement-Based Spinal Assessment Questionnaire
Work: Mechanical Stresses
Leisure: Mechanical Stresses
Functional Disability From Present Episode
Functional Disability Score
Present Symptoms
Commenced as Result of
Symptoms at Onset
Constant Symptoms
Intermittent Symptoms
Bladder
Current Complaints / Gains
Prior Level of Function
Current Functional Limitations
Pain
Medical History

Objective Tab

Inspection
Outcome Measurement Tools
Observation
Range of Motion
Strength
Neuro-Vascular
Special Tests
Palpation

Assessment

Patient Clinical Presentation
Rehab Potential
Goal List

Plan

Procedures
Modalities

Billing

Untimed Codes
Direct Timed Codes