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
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