SOAP 2.0 | Non-Medicare Placeholder Evaluation
  • 26 Mar 2024
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SOAP 2.0 | Non-Medicare Placeholder Evaluation

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Article Summary

Overview

Every case in the WebPT EMR must be opened with an Initial Examination (IE). A Placeholder IE is a no-charge visit that opens the patient’s case for future documentation.
 

Reasons to use the placeholder:

  • You have already performed an IE for a patient either on paper or in different software and want to continue documenting with Daily Notes.
  • Your patient changes insurance mid-treatment and a new IE is not required by the new insurance.

Discover more about Medicare Placeholder IE requirements in 2.0.

 
Click the arrow or colorblock below to discover more.



Visits Prior to WebPT

Visits Prior to WebPT

If you are adding a patient to the WebPT EMR with recorded visits in another software or on paper, you will need to add the visit number to their case. This will allow the Progress Note alert and the visit count field to display appropriately.
 

  1. In the Patient's chart, select Patient Info.
    EMR_1.0_Patient Chart_Patient Info_Default Case Title

  2. In the Cases tab, add the case or edit the existing case.
    EMR_Patient Manager_Patient Info_Patient Case_Edit Case_Default Case Title

  3. Include the visit count, located at the bottom of the Case window. Click Ok to save. If you do not have this field, you’ll need to reach out to WebPT Support and have them turn it on for you.
    EMR_Patient Manager_Patient Info_Case Authorization_Prior Visits field

  4. Save the patient.



Non-Medicare Placeholder

Non-Medicare Placeholder

We recommend having your most recent evaluation available for the patient before starting this process, whether it is a PDF of the note from another case in the EMR or a paper copy.
 

  1. From the patient’s chart in 1.0, use the Click here to document faster button to open the patient’s 2.0 records.
    EMR_1.0_Patient Chart_Click Here to Document Faster_Button_SOAP 2.0

  2. Click Create Initial Evaluation.
    EMR_2.0_Patient Profile_Create Initial Evaluation_Button

  3. Use the Yes radio button to continue. You can select the checkbox for ‘Do not show this again’ to dismiss the alert on future case conversions. Click Apply.
    EMR_2.0_Documentation_Transition to SOAP 2.0_Confirmation

  4. Copy information from the previous evaluation into the appropriate fields. Let’s review the required fields.

  5. Date of Visit. This defaults to today’s date.
    EMR_2.0_Documentation_Date of Visit

  6. Assessment: Diagnosis. You must include the Medical Diagnoses and Treating Diagnoses. Tip: Use the 'Copy All Medical Diagnoses to Treating Diagnoses' link to speed up the entry.
    EMR_2.0_Documentation_IE_Assessment_Diagnosis_Copy All Medical Diagnoses to Treating Diagnoses

  7. Charge Summary: Select the Do Not Bill checkbox to ensure no charges are billed for this placeholder visit.
    EMR_2.0_Documentation_Charge Summary_Do Not Bill




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