SOAP 2.0 | Discharge Summary and Administrative Discharge
  • 05 Dec 2023
  • 3 Minutes to read
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SOAP 2.0 | Discharge Summary and Administrative Discharge

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Article Summary

Overview

SOAP 2.0 Discharge Update

SOAP 2.0 offers the option to automatically remove any future scheduled appointments for cases that have been discharged

When discharging a patient case in SOAP 2.0, providers have two options that function similarly to 1.0. In addition, clerical users can use the Administrative Discharge to discharge a case when necessary.

  • Discharge Summary: Providers can use this note to document the patient’s last visit and bill for the visit.
  • Administrative Discharge: Both Providers and Clerical users can use this option when a patient self-discharges and does not return to therapy for their final visit. This is a non-billable note.
Finalize Any Open Notes

All other notes must be finalized before a discharge can be finalized

Click the arrow below to discover more.



Discharge Summary - Provider

SOAP 2.0 | Discharge Summary - Provider


Typically Providers discharge a case at the end of the patient’s treatment, once all other notes have been completed on the case.

  1. Click (...) from Patient Records and select Discharge.
    EMR_2.0_Patient Profile_Create Discharge_Button

  2. If the discharge note is the result of direct patient interaction during a clinical encounter select Yes.
    EMR_2.0_Documentation_Discharge_Popup_Direct Patient Interaction_Yes

    Administrative Discharges

    If the note is not the result of a direct patient interaction continue to the Provider Administrative Discharge section.

  3. Click Apply to begin the Discharge Summary note and bill for the visit.

Complete the Discharge Summary

You need to complete the Discharge Summary and bill for the visit to complete the Discharge.

  1. Add the required Date of Visit and Date of Discharge and check the box to Remove future appointments if you would like to remove all future scheduled appointments for the patient.
    EMR_2.0_Documentation_Discharge_Discharge Summary_Date of Visit_Date of Discharge

  2. You’ll need to update or click Add to Note for the Patient Presentation subsection.
    EMR_2.0_Documentation_Discharge_Discharge Summary_Subjective_Add to Note

  3. Medicare patients: You’ll need to update or click Add to Note for the Standardized Test subsection.
    EMR_2.0_Documentation_Discharge_Discharge Summary_Objective_Add to Note

  4. In the Plan section, expand the Discharge Summary subsection and complete the information.
    EMR_2.0_Documentation_Discharge_Discharge Summary_Plan_Discharge Summary Subsection

  5. Update your Charge Summary to accurately bill for the visit.

  6. When we’ve completed and signed the note, the patient’s case will have a D/C indicator next to the case name.
    EMR_2.0_Patient Profile_Case Summary_Discharged

  7. The case will also be discharged in SOAP 1.0.
    EMR_1.0_Patient Chart_Discharged Case_SOAP 2 example

Convert Discharge Note to Progress Note

If you create a discharge note for a patient, and determine during the examination that they are not ready to be discharged, you can convert the signed note to a Progress Note.



Administrative Discharges

SOAP 2.0 | Administrative Discharges

Administrative Discharges can be completed by a provider or a clerical user when a patient does not return to therapy.

Provider Administrative Discharge

  1. Providers can also create an Administrative Discharge from the patient Record, open the (...) and select Discharge.
    EMR_2.0_Patient Profile_Create Discharge_Button

  2. If the discharge note is not the result of direct patient interaction during a clinical encounter select No and click Apply. Complete the Administrative Discharge note (this does not have a billing section).
    EMR_2.0_Documentation_Discharge_Popup_Direct Patient Interaction_No

  3. Add the required Date of Discharge and check the box to Remove future appointments if you would like to remove all future scheduled appointments for the patient. Then complete and sign the note. The case will be discharged in SOAP 2.0 and 1.0.
    EMR_2.0_Documentation_Discharge_Administrative Discharge_Sign_Button

Clerical Administrative Discharge

  1. Clerical Users can create an Administrative Discharge from the patient Record, open the (...), and select Administrative Discharge.
    EMR_2.0_Patient Profile_Create Administrative Discharge_Button_Clerical

  2. Add the required Date of Discharge, and check the box to Remove future appointments if you would like to remove all future scheduled appointments for the patient. Then complete and sign the note.
    EMR_2.0_Documentation_Discharge_Administrative Discharge_Remove All Future Appointments

  3. Once the note is completed and signed, the case will be discharged in SOAP 2.0 and 1.0.

Don’t: Converting An Administrative Discharge

We do not recommend converting an Administrative Discharge to a Discharge Summary. This is because no fields will carry forward from your last note. If you’d like to move from an Administrative Discharge to a Discharge Summary, we recommend deleting the Administrative Discharge and creating a new Discharge Summary note using the process described above.

EMR_2.0_Documentation_Discharge_Do Not Convert Discharge




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