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How to Create an Initial Evaluation (SOAP 1.0)

Ready to create an Initial Evaluation? 

Check out this video for Medicare patients.

Check out this video for Non-Medicare patients.

Initial Examination Field Details 

Subjective Tab

Visit #: Tracks the number of completed visits including the IE, daily note, and progress note.

Time In/Time Out: Clicking “Yes” allows you to enter when the patient arrived and left the appointment. Note: This field along with the others that default as “no” are omitted entirely from the final note if left as “no."

Visits from the Start of Care (SOC): For Medicare patients, the visits field reads differently and automatically updates to reflect the patient’s number of visits based on finalized notes. 

ICD Code Favorites: For codes you use often, try using the “favorites” feature. After searching for a code, use the star icon to the right of it to save it to your favorites list. From then forward, click the Favorites tab in the ICD code section to open all of your favorite codes. Then select the codes you want to add to the case. 

Injury/Onset Date/Change of Status Date: Consider this date to be the date of injury if the patient knows it or an onset date if they only know when they noticed the problem, and if they only know when they noticed the problem, and if they don’t know either date, then it can be considered as change of status (when they decided to visit you). Date must be prior to the initial exam date.

Surgery Performed and Prior Hospitalization: When these fields are marked Yes, they expand to allow you to enter additional details about the events. 

Pelvic Profile/Speech Profile: Selections will add more fields to the prior level of function section, allowing therapists to notate specific needs and details. 

Movement-based spinal assessment questionnaire: Selecting Yes, reveals the questionnaires available for further assessment. 

History of Present Condition/Mechanism of Injury and Primary Concern/Chief Complaint: These are required free text fields regarding the patient’s condition. The Smart Text Option gives you the ability to add preloaded phrases to areas of the note, increasing consistency and efficiency. 

Prior Level of Function and Current Functional Limitations: While it is no longer required by Medicare, you can select “self care” when needed or preferred. Clicking one of the limitations opens the available functional options and a free text field for additional details. Selecting Add All, allows you to expand and complete each section according to the patient’s prior level of function (before or after injury). You can also select each section as it pertains to the patient.

Pain Section: Allows you to type in the location, levels, and description, as well as the aggravating factors.

Pain Scale: This section allows you to assess and complete pain factors as indicated by the patient for the condition. Use the radio buttons to describe the patient’s pain levels. Use the drop down menu to set a custom pain description and enter care information in the pain follow up plan field. Clicking Add Additional Pain Scale opens a second pain scale where you add a pain description from another location. 

Restrictions and Pain Alleviators: Clicking Yes, allows additional note options to include Worse With, and Better With, notes about the patient’s condition.

Medical History Fields: These are optional fields. To add information click Yes to expand the fields where you can include the medical history details. Note: If you have uploaded the patient history in an eDoc, click Other and type in See eDoc. There is no need to fill in the patient’s medical history if it is already in the patient chart as an eDoc. 

Objective Tab

The objective tab contains collections of WebPT and custom test/exam profiles to be used for patient examinations.

Add Tests: Use the search box to search for the available tests associated with the patient’s condition. This search will bring up all available tests for that search term. You can choose the one you want to add. Then, click the play button to see how the body mass index test is filled out. 

BMI Inspection: The WebPT EMR produces several different formats that allow for easier data entry, depending on the test selected. The BMI test enables you to enter the weight/height and automatically calculates the index. 

Range of Motion: For the range of motion tests, you’ll be provided preloaded measurements specific to the tests that you can select from. If needed, you can also enter a custom entry in these fields.

Special Tests: There are several tests that don’t belong to a specific section of tests. To locate these, you can type in keywords for the system to pull up matching results; additionally, you can enter Special Tests into the search box to pull tests not connected to any specific section. 

Assessment Tab

Assessment/Diagnosis: The patient’s “assessments/diagnosis” is a required field. You can use smart text to help complete your assessment of the patient. 

Patient Clinical Presentation: You can choose a different complexity level from the subjective selection, as there is a different clinical set of info/data in use for the assessment tab/section. 

Parent/Patient Education: Complete the Parent/Patient Education as necessary. We suggest typing See HEP or including a dated log of references with detail

Contraindictions to Therapy: Clicking Yes reveals a text box to notate items such as travel that might disrupt treatment.

Consent to Care: This field is not required, as this is often on file from the beginning of treatment. If needed and details are uploaded, you can make a notation to See eDoc

Problem List: You’re required to enter at least one problem description

Plan Tab

This section allows you to document your treatment plan.

Patient Status Update Only: Check this box to create a non-billing visit.

Create Plan of Care Document: Use this option to create a single page document for the physician to easily view and sign.

Frequency: Drop down menu of visits per week.

Duration: Select how long the plan of care is in weeks. You can then set the exact dates for the plan. 

Treatment to be Provided: This section lets you select the appropriate procedures, modalities, and specialties. 

Note: Utilize the text boxes for general or specific details. Keep in mind the more specific you are, the more likely you may need to change the plan of care if the plan changes significantly. Use “Other” under Specialties to add any information not already available to you in this section. 

Billing Tab

There are several optional fields. You can enter notes about the case or patient that will appear for every appointment going forward. Note: The Billing Tab can be customized for your organization's specific needs, such as removing fields that your practice doesn't use.

The Daily Note Plan field defaults to Progressing Patient Next Visit. You can add text that you or other providers may need for the next day of service.

Billing Sheet Section: Works in the same manner as the daily note plan section. Use the precautions field to enter important notes that should be considered during care. For example: if the patient has latex allergies, uses a pacemaker, etc. 

Objective Findings: Enter items related to patient care that you want to see in future notes. For example: notes based on tests or measurements taken. 

Pre-Treatment and Post-Treatment: These fields are used infrequently, but when used are mainly for procedures not being billed out, such as applying cold paces before providing services or hot packs after. 

WebPT Recommended Untimed Codes: Depending on the case, the EMR will recommend billing codes to use and describe the reasons in a suggestion box. The suggested billing codes will be underlined. It is okay to not use the WebPT suggestions; there will be NO alerts or notifications within the finalized note of the recommended billing codes. The suggestion box with details will also disappear from the final note. The help icon (?) provides a link to the full descriptions of the suggested billing codes. 

Untimed Codes: Each selection made opens up a field(s) where you can enter the time spent and allow providers to include additional information as needed.

Direct Timed Codes: Select the item, then add the number of units/number of minutes. Notice that when you make selections in this section it will auto-populate with “see flowsheet” You can enter additional information in this text box if desired. Use the open flowsheet link to view the auto populated best example of the exercises. 

Billing Rules for Medicare Codes: Be aware of Medicare billing rules that may apply, such as the 8 minute rule when completing billing for Medicare. The WebPT EMR will detect inaccuracies and kick you back to the billing page and note in red the items that are incorrect. 

Finalize Note Options

At the bottom of the billing tab, you have the option to finalize the note. 

Forward Exam: For users such as PT assistants, there is an option to select a provider and forward them the initial examination. 

Preview and Finalize: Use the preview option to review the accuracy of the Note and Plan of care, as well as see how the finalized note will look once finalized. Selecting Preview also triggers the EMR to review the Initial Evaluation and will kick you back to the tabs needing further attention. Select Finalize once you have completed your review. 

Preview Note: When a PDF preview loads, it means that your note was accepted. You can then review and finalize it.  

Plan of Care Preview: The Plan of Care note includes the assessment, plan, and signature line for the physician to obtain re-certification. 

Make More Changes and Finalize Document: Both of these buttons are at the top right of the preview screen. If you preview the note and realize you need to make changes, you can use the Make More Changes button to go back to the note. If you’re ready to complete the IE click Finalize Document. 

Once you finalize a note, you’ll be brought back to the Patient Chart, where a confirmation message “Document successfully finalized” appears.

Finalized Note Options: Once a note is finalized, you can view, print, fax, or send to the doc portal. Selecting the fax feature opens a pop-up window where you can add recipients, attach other documents, and include a message. 

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