SOAP 2.0 | Workflow Practice Exercises
  • 30 Nov 2023
  • 8 Minutes to read
  • Dark
    Light
  • PDF

SOAP 2.0 | Workflow Practice Exercises

  • Dark
    Light
  • PDF

Article Summary

Overview

This exercise provides everything you need to practice setting up physicians, insurances, and patients, and completing an IE in WebPT, for both a Medicare and non-Medicare patient. Follow the tasks in order to understand the correct workflow for entering information into WebPT and then documenting on patients.

The correct workflow for entering information into WebPT is:

  • Enter Insurance Information
  • Enter Physician Information
  • Enter Patient Information

Task 1 Add Insurances

Create 2 insurance companies in the Insurance Manager. Not every field will be filled out; this exercise is to show you how information carries through the software.

Insurance 1

  • Type: Medicare
  • Name: Red Tape Insurance
  • Phone: 555-867-5309
  • Fax: 555-864-5308
  • Address: 123 Main St. Phoenix, AZ 85004

Insurance 2

  • Type: Commercial
  • Name: Everything Bagel Insurance
  • Phone: 555-867-5309
  • Fax: 555-864-5308
  • Address: 456 WebPT Ave., Phoenix, AZ 85004

Task 2 Add Physicians

Create 2 physicians in the Physician Manager. Not every field will be filled out; this exercise is to show you how information carries through the software.

Physician 1

  • Dr. Type: MD
  • Send Preference: Fax
  • Name: Marcus Welby
  • NPI: 9999999995
  • Phone: 555-867-5309
  • Fax: 666-864-5308
  • Address: 123 WebPT Ave., Phoenix, AZ 85004
  • Email: marcuswelbymd@webpt.com

Physician 2

  • Dr. Type: MD
  • Send Preference: Email
  • Name: Doogie Howser
  • NPI: 9999999995
  • Phone: 555-867-5309
  • Fax: 555-864-5308
  • Address: 456 WebPT Ave., Phoenix, AZ 85004
  • Email: drdoogieh@webpt.com

Task 3 Add Patients

Create 2 patients in the Patient Manager. Not every field will be filled out; this exercise is to show you how information carries through the software.

If you prefer, use diagnosis codes and narrative that reflects the treatment you provide to patients.

Patient 1, Medicare

Patient Info

  • Name: Donald Duck
  • Nickname: Donnie
  • Gender: Male
  • Birthdate: 01/01/1947

Add Address/Contact

  • Home Address: 123 WebPT Ave., Phoenix, AZ 85004
  • Contact: Phone: 555-867-5309 - set as Mobile, and set Appointment Reminders to Text Message

Add Insurance

  • Select Medicare
  • HICN: MC88888
  • Policy Dates: set to January 1 to December 31 of the current year
  • Copay/Coinsurance: select Copay and enter $30
  • Set Prior Existing OT and PT/SLP Treatment: $100 in Approximate dollar amount for PT/SLP Treatment

Add Case

  • Title: Lumbago 2019

  • Primary Insurance: Medicare

  • Diagnosis Code: M54.41, Lumbago with sciatica, right side

  • Related Cause: None of the Above

  • Referring Physician: Dr. Marcus Welby

  • Assigned Therapist: select any name

  • Additional Info: Type in "Patient is hard of hearing"

  • Authorization Required: Yes

             Auth Visits: 10
             Effective Start: enter date of IE
             Effective End: enter date 90 days past date of IE
    
  • Click the Save Patient button

After saving, you will see the patient chart. Please become familiar with where to find:

  • Patient information - date of birth, age, address, phone number
  • Case information - therapist, physician, insurance, diagnosis code
  • Visit tracking - visits in case, visits in an active episode of care, visits until an evaluative note, authorized visits by count, authorization expiration date, cancelations, and no shows for appointments
  • Additional Info - entered into the case (Patient is hard of hearing)
  • Medicare Threshold - shows thresholds for the calendar year and previous amount spent on Medicare visits

Patient 2, Non-Medicare

Patient Info

  • Name: Minerva Mouse
  • Nickname: Minnie
  • Gender: Female
  • Birthdate: 07/04/1978
  • Other Info: Type in "Patient will pay every two weeks, not at every session"

Add Address/Contact

  • Home Address: 123 WebPT Ave., Phoenix, AZ 85004
  • Contact: Phone: 666-666-666
  • Email: mmouse@webpt.com
  • Appointment Reminders: check box

Add Insurance

  • Everything Bagel
  • Subscriber ID: 7777777
  • Visits Allowed: 24
  • Policy Dates: set January 1 to December 31 of the current year
  • Copay/Coinsurance: select Coinsurance and enter 80%
  • Insured Party: select Spouse, enter spouse info including birthdate 03/06/1983, click Copy Address From Patient button

Add Case

  • Title: R Knee

  • Primary Insurance: Everything Bagel

  • Diagnosis code: S83.511A, Sprain of anterior cruciate ligament of the right knee, initial encounter

  • Related Cause: Sports Injury

  • Referring Physician: Dr. Doogie Howser

  • Assigned Therapist: select any name

  • Other Info: Type in "Prior surgery on left knee"

  • Record Prescription: Yes

     Start Date: date of IE
     End Date: 30 days from date of IE
     Number of Visits: 4
    
  • Click the Save Patient button

After saving, you will see the patient chart. Please become familiar with where to find:

  • Patient information - date of birth, age, address, phone number
  • Case Information - therapist, physician, return to doctor date, insurance, diagnosis
  • Visit tracking - visits in case, insurance policy visits allowed, insurance policy expiration date, cancels and no shows
  • Other Info - entered into Patient Info (Patient will pay every two weeks, not at every session)
  • Additional Info - entered into the case (Prior surgery on left knee)

Task 4 Initial Exam for Non-Medicare Patien

Document on Non-Medicare patient Donald Duck. Not every field will be filled out; this exercise shows you how information carries through the software.

If you prefer, use diagnosis codes and narrative that reflects the treatment you provide to patients.

Open an Initial Examination and enter the following information in each section.

Prior to accessing the Subjective section, enter the Date of Visit: 3/8/2019, 11am-11:45am

Subjective Section

Patient Presentation

  • Primary Concern: Lower Back
  • History of Present Condition/Mechanism of Injury: Acute low back pain
  • Injury/Onset Date/Change of Status Date: 1/16/2019
  • Patient/Caregiver Goals: No pain while standing for extended periods of time.

Past Medical History

  • Previous and Current Conditions: Click the search field to open the drop-down menu, then click the check box for “Other”. Then, type in the following: “Back- pain in lower back affecting other lower extremities”
  • Complicating/Personal Factors: Check the box for “No Known Complicating or Personal Factors Affecting the Plan of Care”

Current Medications

  • Click Medications +
  • Medication Type: Over the Counter
  • Name: Ibuprofen
  • Additional Comments: patient is taking Ibuprofen, 800mg, three times per day, orally

Social History

  • Tobacco Use: Select No
  • Primary Concern/Chief Complaint: Pain radiates down right leg after long car trips
  • Medical History Review: select Moderate Complexity

Objective Section

Standardized Tests

  • Click Add Standardized Test+
    • Select Lower Extremity Functional Scale
    • Rate Pain Level: (10) Very Severe Pain
    • For Questions: 1,2,5,6,7,9,11,12,13,14,15,16,17,18,19- Select: Extreme difficulty or unable to perform activity. (0)
    • For Questions: 3,4,8,10,20- Select: No Difficulty. (4)
  • Additional Comments: In extreme pain most of the time.

Body Measurements

  • Height: 56 inches
  • Weight: 180lbs
  • Follow-up Plan: General nutritional counseling

Activities/Interventions

  • Precautions: Fall risk
  • Click Add activity
    • Search: Gait
      • Select: Gait with a straight cane
      • Click Add Activities
  • Fill out the following information and click the checkmark on the far right:
  • Billable Procedures: 8 Minutes

Assessment Section

Diagnosis

  • Medical Diagnosis:M54.41, Lumbago with sciatica, right side
  • Treating Diagnosis: click Copy All Medical Diagnoses to Treating Diagnoses
  • Precautions: Fall Risk
  • Additional Comments:The patient presented with acute pain and episodic shooting pains. Sciatica aggravated by long periods of long-distance driving.

Problems & Goals

  • Rehabilitation Potential: Good
  • Select the checkbox for: The plan of care addresses the identified functional outcome deficiencies and details are documented in the visit note.

Patient/Caregiver Education

  • Education Provided:HEP
  • Additional Comments: Patient will follow exercises at home via HEP

Clinical Complexity

  • History: 1-2 Personal factors and/or comorbidities (Moderate)
  • Examination of Body System(s): Addresses 1-2 elements (Low)
  • Clinical Presentation: Evolving (Moderate)
  • Level of Clinical Decision Making: Problem-focused assessment (Low)
  • Overall Rating of Evaluation: Moderate Complexity

Plan Section

Planned Treatment and Schedule

  • Approach: Begin/continue plan as outlined
  • Frequency: Once per week
  • Duration: 6 Weeks
  • Planned Procedures: select Therapeutic Exercises and Manual Therapy Techniques

Charge Summary Section

  • Click CPT Code
    • Select 97110- Therapeutic Exercise
      • Modifier: GP
      • Minutes: 8
      • Unites: 1

Finalize the Note: Click Sign at the top of the screen.

Task 5 Initial Exam for Medicare Patient

Document on Medicare patient Minerva Mouse. Not every field will be filled out; this exercise is to show you how information carries through the software.

If you prefer, use diagnosis codes and narrative that reflects the treatment you provide to patients.

Open an Initial Examination and enter the following information in each section.

Prior to accessing the Subjective section, enter the Date of Visit: 3/8/2019, 11am-11:45am

Subjective Section

Patient Presentation

  • Primary Concern: Lower Back
  • History of Present Condition/Mechanism of Injury: Acute low back pain
  • Injury/Onset Date/Change of Status Date: 1/16/2019
  • Patient/Caregiver Goals: No pain while standing for extended periods of time.

Past Medical History

  • Previous and Current Conditions: Other: Back- pain in lower back affecting other lower extremities
  • Complicating/Personal Factors: Check the box for “No Known Complicating or Personal Factors Affecting the Plan of Care”

Current Medications

  • Click Medications +
    • Medication Type: Over the Counter
    • Name: Ibuprofen
    • Additional Comments: patient is taking Ibuprofen, 800mg, three times per day, orally

Social History

  • Tobacco Use: Select No
  • Primary Concern/Chief Complaint: Pain radiates down right leg after long car trips
  • Medical History Review: select Moderate Complexity

Objective Section

Standardized Tests

Note: You must include at least one standardized test in the Objective Section for Medicare patients

  • Click Add Standardized Test+
    • Select Lower Extremity Functional Scale
    • Rate Pain Level: (10) Very Severe Pain
    • For Questions: 1,2,5,6,7,9,11,12,13,14,15,16,17,18,19- Select: Extreme difficulty or unable to perform activity. (0)
    • For Questions: 3,4,8,10,20- Select: No Difficulty. (4)
  • Additional Comments: In extreme pain most of the time.

Body Measurements

  • Height: 56 inches
  • Weight: 180lbs
  • Follow-up Plan: General nutritional counseling

Flowsheet Section

Activities/Interventions

Precautions: Fall risk
Click Add activity
Search: Gait
Select: Gait Training with a straight cane
Click Add Activities
Fill out the following information and click the checkmark on the far right:
Billable Procedures: 8 Minutes

Assessment Section

Diagnosis

  • Medical Diagnosis: M54.41, Lumbago with sciatica, right side
  • Treating Diagnosis: click Copy All Medical Diagnoses to Treating Diagnoses
  • Precautions: Fall Risk
  • Additional Comments: The patient presented with acute pain and episodic shooting pains. Sciatica aggravated by long periods of long-distance driving.

Problems & Goals

  • Rehabilitation Potential: Good
  • Select the checkbox for: The plan of care addresses the identified functional outcome deficiencies, and details are documented in the visit note.

Patient/Caregiver Education

  • Education Provided:HEP
  • Additional Comments: Patient will follow exercises at home via HEP

Clinical Complexity

  • History: 1-2 Personal factors and/or comorbidities (Moderate)
  • Examination of Body System(s): Addresses 1-2 elements (Low)
  • Clinical Presentation: Evolving (Moderate)
  • Level of Clinical Decision Making: Problem-focused assessment (Low)
  • Overall Rating of Evaluation: Moderate Complexity

Plan Section

Planned Treatment and Schedule

Note: For Medicare documentation, you must complete the approach, frequency, and duration

  • Approach: Begin/continue plan as outlined
  • Frequency: Once per week
  • Duration: 6 Weeks
  • Planned Procedures: select Therapeutic Exercises and Manual Therapy Techniques

Plan of Care

  • Select checkbox for This note is a Medicare certification
  • The Plan of Care effective dates will auto-populate based on the information you entered for frequency and duration

Charge Summary Section

  • Click CPT Code
  • Select 97110- Therapeutic Exercise
  • Modifier: GP
  • Minutes: 8
  • Unites: 1
    Finalize the Note: Click Sign at the top of the screen.

Was this article helpful?