SOAP 2.0 | Progress Notes
  • 05 Apr 2024
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SOAP 2.0 | Progress Notes

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Article Summary

Overview

Use Progress Notes to evaluate your patient as they progress through treatment. A Progress Note should be completed for Medicare patients after 9 Daily Notes.

Non-Medicare Patients

There is no Progress Note requirement built into SOAP 2.0 for non-Medicare patients.

Medicare Compliance
  • A Progress Note will be required after 9 Daily Notes are finalized to comply with Medicare documentation requirements.
  • The Daily Note option will be disabled until a Progress Note is finalized.
  • Progress Notes that are marked as a re-certification must have updated Plan of Care dates with an end date in the future. Discover more about Medicare Plans of Care.

Click the arrow or colorblock below to discover more.



Progress Notes

SOAP 2.0 | Progress Notes

 

  1. Click Create Progress Note. Your Progress Note type may be hiding in the (...) menu.
    EMR_2.0_Patient Profile_Create Progress Note_Button

  2. Progress Notes allow you to update the title of the note to comply with insurance requirements as needed. Discover more about Updating Progress Notes.
    EMR_2.0_Documentation_PN_Convert Note_Rename Note

  3. Similar to the Daily Note, you must edit the Patient Presentation subsection or click Add to Note.
    EMR_2.0_Documentation_Discharge_Discharge Summary_Subjective_Add to Note

  4. Medicare Patients: You’ll need to update your Standardized Test and the Plan of Care dates (if needed).

    a. Re-administer the Standardized Test from the Objective section. Alternatively, you can click Add to Note.
    EMR_2.0_Documentation_PN_Objective_Standardized Tests_Add to Note_Button

    b. If you need to update the patient’s Plan of Care dates, start by navigating to the Plan of Care Dates subsection (Assessment).
    c. Check the This note is a medicare Re-Certification box.
    EMR_2.0_Documentation_Plan of Care_This Note is a Medicare Re-Certification

    d. This allows you to update the Plan of Care Effective Dates. The From date automatically updates to the current date and the To date is determined by the Duration selected in the Planned Treatment and Schedule subsection.
    EMR_2.0_Documentation_Plan of Care Effective Dates_Fields

  5. Click into the Charge Summary section to update the Minutes for our Timed Codes and add any additional codes like a Re-Eval code.
    EMR_2.0_Documentation_Charge Summary_Re-Evaluation

  6. Click Sign when ready.
    EMR_2.0_Documentation_Sign Button




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