Initial Evaluation

Let’s review how to create an Initial Evaluation (IE) for your patient. Remember, each new case must begin with an IE.

Starting the Initial Evaluation

1. From the Patient Record page in the WebPT EMR, use the Click here to document faster button to navigate to 2.0.
   
2. This is the patient’s Records page. Here you can view information about the patient’s case and any previously created notes. Click here to learn more.
3. Let’s begin documenting for this patient by clicking Create Initial Evaluation.
   
4. If you want to add a different type of note, you can click the (...) menu and choose from the available options. These options change based on what other notes have been completed for the patient.
   
5. You’ll need to confirm that you want to begin documenting in SOAP 2.0, as this process is irreversible. Select the Yes radio button and click Apply. You can select the checkbox next to Do not show this again if you don’t want to be prompted each time you begin a new SOAP 2.0 case.
   
6. To add a Profile, click the Menu [...] button and select Add Content. 
7. Use the Eval/Note Profile section to select your desired profile and click Apply. The Add Content window also allows you to add additional content subsections to the note that are not on the existing Template or Profile.   

Subjective Section

The subjective section allows you to enter information about your patients, including their Social and Medical History. 

1. The note begins with the Patient Presentation subsection in Edit mode. This is when a subsection is open and ready for data entry.
   
   1. Be sure to include the required field: Date of Injury/Onset.
2. Data entered in the Patient/Caregiver Goals section will automatically populate in the Goals section of the Case Summary.
   
3. Opening the next subsection automatically closes the previous section, enabling Read-mode. This automatically hides empty fields and clearly displays fields containing data.
   

Objective Section

The Objective section allows you to summarize your findings.

1. You can add Standardized Tests by clicking the Add Standardized Test+ link and selecting the test from the drop-down. Important: Scores will not auto-calculate.
   
2. Added a test on accident? Simply click the Menu (...) and select Delete to remove it.
   
3. Use the Flowsheets subsection to add in your patient exercises. If you’re documenting your Flowsheet on paper right now, this functionality is ideal for you. Click here to learn more.
   

Assessment Section

This section allows you to enter your Diagnosis, Areas of Concern, and related Goals.

1. The Medical Diagnosis and Treating Diagnosis are required fields. The Medical Diagnosis pulls from the diagnoses entered on the patient’s case. Opening this section allows you to enter additional Medical and Treating Diagnoses, and even copy your Medical Diagnoses to your Treating Diagnoses. 
   

1. The Diagnosis section also allows you to enter any factors, complicating or supportive. 
2. In the Problems & Goals section (Areas of Concern & Goals for Habilitative profile patients), start by adding a problem by clicking Problem+. This section allows you to list your patient’s problems and then add related goals.
   
3. For each problem, use Goal+ to add one or more goals.
   
4. You can add one or many related goals to each Problem (or Area of Concern).
   

Plan Section

The Plan section allows you to detail the patient’s treatment plan. This is also where you will create the Plan of Care for your Medicare patients. 

1. You must include an Approach and Duration for patients with Medicare insurance.
   
2. Leverage Profiles to automatically select Planned Procedures when the profile is loaded, or select them from the drop-down.
   
3. In order to create a Plan of Care, you must select the ‘This note is a Medicare certification’ checkbox. Note: Your Plan of Care Effective Dates will be grayed out until the box is selected. Checking this box will also update the title of the note to 'Initial Evaluation - Certification.'
   
4. Once the checkbox has been selected, the From date will automatically be set to today’s date. The To date will automatically populate based on the Duration chosen in the Planned Treatment and Schedule section.
   

Charge Summary Section

This section allows you to enter charges based on the performed procedures, or you can choose not to bill for this visit. Billing information is included in the finalized note, negating the need for a separate Daily Note. This is an improvement over the current SOAP 1.0 configuration.

1. Select CPT Code+ link to add a charge. Indicate the CPT Code and then select the appropriate Modifiers, enter Minutes, and/or Units. Click here for a deep dive into the Charge Summary and its functionality.
   
2. If you don’t want to bill for the visit, check the 'Do Not Bill' box. The Charge Summary section will act as a record of the procedures performed during the visit.
   

A Note About Charges

• SOAP 2.0 automatically prioritizes CPT codes based on Planned Procedures
• If the payer on the patient's case has Additional Modifiers designated in Insurance Settings, then the additional modifiers will be available for selection in the SOAP 2.0 Charge Summary.
• A 59-modifier will be automatically applied on designated CPT codes as indicated by the CCI Edits setting in Insurance Settings. You will be unable to de-select these modifiers from the Modifier drop-down.
• Therapy modifiers (GP, GN, or GO) will be automatically applied to CPT codes if the patient's insurance on the case has Apply Therapy Modifiers selected in their insurance settings. You will not be able to de-select these modifiers from the Modifier drop-down.

Signing the Note

When you are finished with the note, you can click Sign at the top of the page, or use the secondary action menu ( ...) to select another option. 

Once you sign your note, the application will automatically check that the following are present before finalizing:

• Date of Visit
• Start of Care
• Medical and Treatment Diagnosis Codes
• A Standardized Test (Medicare-only)
• Charge Summary (either CPT Code(s) or selecting Do Not Bill)

If all items are present, the note will be signed and saved into the patient’s records.