Medicare Placeholder Evaluation (SOAP 2.0)
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.
For non-Medicare Placeholder IE requirements in 2.0, click here.
Visits Prior to WebPT
If you are adding a patient to WebPT who have had prior 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.
- In the Patient's chart, select Patient Info.
- In the Cases tab, add the case or Edit the existing case.
- 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.
- Save the patient.
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.
- From the patient’s chart in 1.0, use the ‘Click here to document faster’ button to open the patient’s 2.0 records.
- Click Create Initial Evaluation.
- 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.
- Copy information from the previous evaluation into the appropriate fields. Let’s review the required fields.
- Date of Visit: This defaults to today’s date.
- Subjective: Start of Care. This defaults to the date listed for the Date of Visit field.
- Objective: Standardized Test. Click the Add Standardized Test+ link to select and complete the test.
- 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.
- Plan: Planned Treatment and Schedule. Complete the Approach and Duration fields by choosing values from the drop-down.
- Plan: Plan of Care Dates. Once you select a From date, the To date will automatically be updated based on the Duration selected above.
- Charge Summary: Select the Do Not Bill checkbox to ensure no charges are billed for this placeholder visit.