Documentation Note Types (SOAP 2.0)
In addition to notes that are part of the patient's medical records (evaluative notes and daily notes), you can create notes that are not part of the medical record (chart alerts) that others in your clinic can read.
Medical Record Notes
The following notes are available from the Records section of the patient profile.
- Initial Evaluation (IE): used during the first visit or initial encounter with the patient. You will cover medical history, diagnosis, tests and measurements, problems and goals, and create a Plan of Care (POC), as well as have the option to include treatment and billing codes. Documentation in each case must start with an IE.
- Because each case requires an Initial Evaluation to start, we have instructions for creating Placeholder IE for Medicare and Non-Medicare patients when you need to start a new case for a patient you've already been treating. This typically occurs when you start using WebPT or if the patient changes insurance mid-treatment.
- Daily Note (DN): used for documenting a general therapy session when there are no significant changes to the patient’s diagnosis or status. You can document how they are feeling and what activities and treatments were performed that day.
- Progress Note (PN): required periodically by insurances, such as every 10 visits for Medicare patients. Use the PN to monitor the status of your patient's progress. You can administer the same tests documented in the IE and take measurements again to determine if treatment needs to be adjusted. Progress notes can be renamed to a Re-evaluation or Re-examination, or labeled as a Recertification for Medicare patients.
- Discharge: There are two discharge note types available under the Discharge selection. Depending on how you respond to the pop-up, you'll be directed to one of the following notes:
- Discharge Summary: used when treatment is completed or the patient decides to end treatment, and you are documenting the last visit. Here you will take any final measurements or tests to determine how the patient has improved, discuss any post-rehab goals, and officially discharge the patient from therapy. This is a billed visit.
- Administrative Discharge: used if a patient does not return for treatment and you want to close the case. This is not a billed visit. Briefly document why the case is closed; for example, the patient moves or decides not to return for treatment.
Note: You can add an Administrative Discharge to a patient case before you've completed an evaluation if you need to close the case but do not want to inactivate or discharge the patient.
- Case Note: a brief, non-billable note used to record information that does not necessarily relate to treatment. Some examples: a patient needs an explanation for missing work; a student-athlete needs a note stating they can return to sports; a case manager needs your opinion on the patient. Case Notes are officially part of the patient’s medical record and cannot be deleted. However, you can addend case notes.
If you need to document information on the patient's chart that is not part of the patient's medical record, we recommend adding custom alerts. These are essentially virtual sticky notes which can be edited or deleted at any time.
- The patient is hard of hearing
- The patient requires a translator
- The patient needs transportation assistance