Patient Notes

Patient Notes is an  Analysis Grid style report that includes SOAP 1.0 and 2.0 data on patient finalized notes including treating diagnoses, documenting, and finalizing therapists. This report primarily contains information associated with the patient’s case and the related notes. To learn more about Common Uses for the Patient Notes report, click here.

Data Notes

  • Which notes are included?
    • SOAP 1.0: Finalized notes that are billable, including treating diagnosis. Notes are considered billable as long as they do not contain the code NC001 or NORCM. For evaluative note types to be billable, they must have an included Daily Note.
    • SOAP 2.0: Finalized notes (status of Signed) that are billable as defined above. 
  • Visit Type: If you are documenting in both SOAP 1.0 and 2.0, you will see slightly different naming conventions. For example, Initial Evaluation and Initial Evaluation - Certification are 2.0, while Initial Examination is 1.0. Unhide the Note Source column for additional clarity.
  • Note Status
    • SOAP 1.0: This displays as Active or Discharged.
    • SOAP 2.0: This displays Signed (finalized).
  • Visit Count
    • If you are still using SOAP 1.0, please only count Daily Notes to obtain your overall visit count.

Location

You can locate this report in the Notes section of Reports in Analytics. If you do not see the report listed in this section, ensure that you have the correct Analytics Access permission.

Run and Customize the Report

  1. Choose which clinics appear in the report using the View Clinics by: drop-down menu and corresponding (…) menu.
  2. Select the desired Date Range.
  3. Add Filters to create specific data segments using any of the column values in the report.
  4. Select Add Chart to visualize the data. Charts can be saved and displayed in your custom Dashboards.
  5. Use the Column Headers to Sort, Filter, Group, Aggregate, or Format the report output.
  6. Once you've manipulated the report to your liking, you can save the customizations and re-run or share the report later with Saved Reports.

Treating Diagnosis Tips

  • Many cases contain multiple treating diagnoses. If you want to break up the diagnoses into individual columns, we suggest downloading the report as an Excel file. We have included pipe separators to allow Excel’s automated Text-to-Columns feature to easily section out codes into their own columns.
  • If you’d like to segment out a single diagnosis code, we suggest using the Contains comparison option to capture the treating code. This will display the code where it appears on its own and as a component of a string of diagnoses.

Column Field Descriptions

Field Name Definition Source
Clinic Name The clinic location where the patient's note was finalized. Patient Notes
Patient Name The patient's name, as entered in the Patient Info section of the patient chart. First Name and Last Name fields in the Patient Info section
Date of Service The date of service listed in the patient's note. Date of Service field in the finalized SOAP Note
Date of Finalization The date and time the note was finalized/signed. Patient Notes
Documenting Therapist Type The type of user who forwarded the note. If the note was not forwarded, this field will default to the user type of the provider who finalized the note.  User Type drop-down in the Add/Edit User page
Documenting Therapist The provider who forwarded the note. If the note was not forwarded, this field will default to the provider who finalized the note. (This ensures that assistant user types are included in Analytics reporting.)  Patient Notes
Finalizing Therapist The provider who finalized the note. For SOAP 2.0: This field will only be populated once the note is finalized. Patient Notes
Case Name The title of the patient's case. This includes active and discharged cases. Case Title field in the Add/Edit Case window
Visit Type The type of note selected (e.g., Daily Note). Quick Discharge note types are not included. If you are documenting in both SOAP 1.0 and 2.0, you will see slightly different naming conventions. For example, Initial Evaluation and Initial Evaluation - Certification are 2.0, while Initial Examination is 1.0. Unhide the Note Source column for additional clarity. Note type selected from the Patient Record.
Note Status
  • SOAP 1.0 Notes: This displays as Active or Discharged.
  • SOAP 2.0 Notes: This displays Signed (finalized).
Patient Note
Treating Diagnosis The ICD-10 (or ICD-9) code(s) the therapist has identified as the treating diagnosis. This may be the same as the referring diagnosis.  Treating Diagnosis section on the finalized patient note
Primary Insurance Type The insurance type of the patient's primary insurance, as listed in the patient's case. Type drop-down in the Add/Edit Insurance window
Primary Insurance The name of the primary insurance listed in the patient's case. Primary Insurance drop-down in the Add/Edit Case window
Secondary Insurance Type The insurance type of the patient's secondary insurance.
Secondary Insurance The name of the patient's secondary insurance.
Note Source (Hidden) Displays where the finalized charge was added (SOAP 1.0 or 2.0). Unhide this field using the Columns option under the Gear icon. Note location