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Under SOAP Notes icon/ Progress Notes icon

SOAP notes – Daily Progress notes

On the function bar - Blue File Folder icon “Show all progress notes” will show you a history of any SOAP notes you have already written

On the function bar from the scheduler only – while on a client appointment - Blue File Folder with Green plus icon will “Create new progress note” for that date of service

Four ways to enter in narrative details

1. Start with content of last note - to make this setting change go to (settings, customize progress notes and documentation – chose bring forward content of last note option)

2. Start with a blank note and/or free-type whatever content you need 3. Use the Copy and paste feature to copy sections from previous notes independently 4. Quick phrasing. To create your own “quick phrases” type something into your document – highlight

those words– use the green plus on right to permanently add that phrase, enter description, file it in a category or make up one. 1. (Mostly used in USA clinics – show fee association option as well) See step 1. Above also chose

to make this setting change go to (settings, customize progress notes and documentation and chose “enable fee association”) this will allow you to associate a fee code with the Quick phrase: Example:

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Within SOAP note use Body Chart icon to indicate injury/diagnosis or areas to comment on

PQRS and FLR reporting for Medicare – USA ONLY

Within SOAP note use Medicare “incident measures” icon to add each PQRS and 1 x FLR measure you are monitoring on this patient. NOTE: If you want to set a DEFAULT list of PQRS measures used on all clients go to Housekeeping, Clinical, Measures – you will see the #’d PQRS measures to the left – on the right tick the box marked “Default”.

Within SOAP note use Target symbol with green plus icon for adding/commenting on GOALS The Master list of goals comes from Housekeeping, clinical, Goals Within SOAP note use Hand symbol to enter treatment – mostly in USA or for any clinic where the

Therapist is the one who is responsible for entering in treatment/assessment codes– alternatively front desk may be doing this task through the scheduler.

Provider Signature and Co provider signature chose names Change status of note to “completed signed” to sign the note (please note NON billable providers may

only be able to chose Completed Unsigned, only a therapist should be able to sign notes potentially. Annotation/Addendum if required after the note is signed is completed by choosing the green plus

from within the note. Print/preview using Printer icon in function bar - chose options prior to printing. The BLUE file folder icon will show ALL soap notes – you can FLAG ALL to print all The blue file folder icon appearing on the scheduler = note is signed and completed by the same

therapist that the appointment is booked with. Please note – (especially in the USA) this session usually leads you to the BILLING training session. The Charges/treatment you typically enter through your clinical notes are what we train on next, thus you need to ensure you have some SOAP notes completed and charges entered on clients so that we can BILL them in the next training session. Even if you are working with a FAKE client, it is important to practice. We must have something to use in the Billing training sessions for it to be effective. Notes

Under “Activities by documents” icon

“Activities by documentation” icon

Five options for adding documents to client area 1. Quick Scan icon – Single image scan only

Quick Scan - Launch Scanner icon to take a single scan

2. Use “New Document” drop down selecting a pre-loaded template (functionality will be the exact same as the SOAP Note above

New Documentation drop down • 5 pre-loaded templates – notice that functionality works just like the SOAP note with Body

Chart, Goals, Hand entry etc. Signatures etc. all function the same way – sections not completed will NOT show up in printed versions.

3. Import document option – finding a document already located on your computer

Import Document – complete the pop up tab, attach document. Open attachment, modify, save, re import button.

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4. Custom Building your own templates/forms (Attached instructions) Custom Documentation – attached written instructions to walk you through the steps

5. As a fifth option you can download any pre-built forms we have from our website such as the

actual Functional Outcomes Tests i.e.: Berg Balance, Dash etc. Go to Help drop down – Integrated forms update – this will take you to our website that will

show you all available forms for download. Select and download your forms. If you need assistance, please contact our support department for help. These downloaded forms will then be listed under “activities by document” , then the Green plus sign “new Document” along with the Pre-loaded templates, the Import Document option and your custom built templates.

Notes

Documentation Reports

Reports, Task/Clinical

• Contact Log follow up report (see below for details) • Physician and evaluation tracking – run a report of all clients with a “next evaluation due

date” within a period of time. This date field comes from the Statistics tab in a client profile OR you can Right click on a client appointment and chose “update incident status”. This date is also shown in the bottom BLUE section of your screen on the left as “Key Patient information”

• Document and progress note status report – run a report of all Incomplete SOAP notes for a period of time.

• Documents on file • Progress note

Notes

Contact Logs

Contact Logs We may not have covered this in training unless it was specifically asked for but here are the instructions:

The first thing you want to do is create some CONTACT LOG CATEGORIES for yourself. HOUSEKEEPING, TASKS, CONTACT LOG CATEGORIES. Add in whatever categories to types of reminders you need. Example:

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Then, no matter what screen you are on, scheduler, list of clients etc. Look for the little PHONE icon, which is a contact log. When you are in Contact Logs, you will create a NEW one by clicking the green plus sign:

Chose your category – The date, add a comment and enter in a FOLLOW UP date if required.

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Then, you can RUN reports for yourself whenever you need. So if I wanted to see a list of all my “MARKETING EFFORT” categories that have FOLLOW UPS coming due by Sept. 30 2010 I would go to REPORTS, TASKS, and CONTACT LOG FOLLOW UP REPORT.

Enter in my date range and my category to check for: And Voila, it will give me a list of all my follow ups that meet those criteria. – You will go back into those logs and either mark them as COMPLETE when you are done, OR you will update them and change the follow up date. It is like an active TO DO list OR a list of contacts made on the file. Notes