Completing a Daily Note

Completing a Daily Note

Each patient visit will require entry of a Daily Note.     

Create a Daily Note

• After the patient's Appointment has been acknowledged, a Daily Note task will be placed on the therapist's work queue. Click the Create Document button to create and open the Daily Note.
• The Daily Note header of the note will display basic case and visit information for the patient (See below screenshot).     
  • Plan of Care / PN Status table displays how many visits are remaining and when the Updated Plan of Care/ Progress Note is due. 
  • You can expand the POC Status as well as the PN status but clicking the question mark next to POC Status or PN Status. 
  • Use the Prev and Next buttons to scroll to the patient's other Daily Notes.
• Precautions - If precautions have been listed in the Initial Evaluation, they will be displayed in the Daily Note. Users may edit this at any time as well as add on additional Precautions
  • To edit the Precautions you will click on the pencil and paper icon after the list of Precautions

**Note: Each tab of the Daily Note will have to be visited even if nothing is entered     

SOAP Note Tab

• Complete the Subjective, Objective, Treatment, Assessment, and Plan section by typing in free text field or following one of the options below.
• Some of the sections give the option to either choose from a templated list that enters text in the field below it and/or copy from the last data entered.
  • Click the list field and make a selection from the drop down list.
  • The selection will populate in the text field. Edit the selection as needed.
  • Additional selections can be added from the drop down list. Each selection will populate a new line in the text box. 

OR

• Click Copy in the box with Last Visit data. This will populate Last Visit data in the free text field below it

OR

• Type data in the Free Text note box

• In the Treatment section, select the See Treatment Log check box and/or enter treatments in the free text field. At least one of the options must be completed before the note can be signed.

Manual/ Treatment Tab

• Any CPT codes that are Manual Treatments and were added to the Initial Evaluation will auto populate into separate CPT code treatment tables on the Manual/ Treatment Tab

Pulling Previous Data Forward

• Click the blue Arrow icon to the left of the bolded Date of Service column
  • This will pull all Treatment Details entered at the previous visit forward to the current date of service

Adding a New CPT to the Manual/ Treatment Tab

• Click in the Select Treatment/CPT Code to Add drop-down menu

• All CPT codes in AgileEMR that are Manual Treatments will be listed for you to select from
• Click the Check Box next to the CPT Codes that need to be added to the Manual/ Treatment tab (this is a multiselect list)

• Click Add
  • This will cause a CPT code treatment table to populate on the Manual/ Treatment tab below the previously added CPT code treatment tables
• Enter the Treatment Title/ Description in the CPT code treatment table under the Treatment column
• Enter Treatment Details in the CPT code treatment table under the Date of Service column
• Click the Green Check Mark icon to the left of the Treatment Details to mark the treatment as performed on for that date of service

• Enter total minutes for all treatments performed that are associated with the CPT code at the bottom of the Date of Service column (the units will auto calculate based on rules assigned)

Removing a CPT from the Manual/ Treatment Tab

**Note: All Treatment rows must be blank and not performed on previous dates of service in order to remove a CPT completely

• Click the Trash Can icon to the right of the CPT Code to remove the code from the Manual/ Treatment tab
• If a Treatment associated with this CPT Code was previously performed you will not be able to remove the CPT Code.
• Click the Trash Can icon to the right of the Treatment to remove the treatment. (you will only be able to do this if there is no treatment details and treatment hasn't been marked performed for previous dates) 

Re-ordering CPT Codes on the Manual/ Treatment Tab

• Click on the Reorder Codes button at the top of the Manual/ Treatment tab

• Drag and drop the Codes into the desired order in the Reorder Codes pop up window

Example: 

Beginning order:

• Click Save Changes once the codes are in the desired order

**Note: If you do not click Save Changes and use the Cancel or X button to close the window the changes will not be saved.

• By clicking Save Changes the codes on the Manual/ Treatment tab will be reordered to the order selected

Ending order:

Exercise Log Tab

Adding a New Treatment to the Exercise Log table

• Enter the Treatment Title/ Description in the Exercise Log table under the Treatment column

• Click the Pen and Paper icon to enter Treatment Details for that date of service

• Enter the following Treatment Details in the Edit Treatment Details pop up window for the Exercise
  • Reps and Sets
  • Weight Used
  • Time in Seconds or Minutes
  • Band, Tube, Speed with Incline, or Speed without Incline Levels
  • Additional Notes for Exercise
• Checking the Add to HEP check box will add the entered Treatment Details to the patient's Home Exercise Program tab within AgileEMR

• Click Save Changes

**Note: If you do not click Save Changes and use the Cancel or X button to close the window the changes will not be saved.

• Click the Check Mark icon to the left of the Date of Service column to mark the Treatment as performed for that date of service (the Check Mark icon will turn green when Treatment is marked performed)

• When a Treatment is marked performed with the Green Check Mark you will see a drop-down menu populate in the Date of Service column by the Pen and Paper icon.

• Any Exercise CPT Codes added to the Initial Evaluation will already be added to the abbreviation drop-down for you to assign to a Treatment (If the desired CPT Code isn't in the Abbreviation drop-down menu from the Initial Evaluation you can add additional codes. Please see the "Adding a New CPT Code to the Abbreviation Drop-Down Menu" section below)
• Assign the desired CPT Code from the abbreviation drop-down menu to the Exercise Treatment for that date of service

Adding a New CPT Code to the Abbreviation Drop-Down Menu

• Click in the Select Treatment/CPT Code to Add box at the top of the Exercise Log tab

• Type the CPT Code or the CPT Code Description
• Select all the CPT Codes you need added to the drop-down menu (this is a multiselect list) 

• Click the Add button once all additional CPT Codes have been checked
• You will see the success message shown below when the codes have been added

• These codes will now be available in the abbreviation drop-down menu for you to assign to a Exercise Treatment

• A CPT Code block will populate at the top of the Exercise Log tab once the CPT Code has been assigned to an Exercise Treatment that is marked as performed

• Enter all Minutes associated with this CPT Code in the CPT Code block 

Adding Additional Treatment Rows

• Click the Plus (+) icon at the bottom right of the Exercise Log table for additional treatment rows

Pulling Previous Data Forward

• Click the blue Arrow icon to the left of the bolded Date of Service column
  • This will pull all Treatment Details entered at the previous visit forward to the current date of service

Removing a Treatment from the Exercise Log Table

**Note: The Treatment row in the Exercise Log Table will need to be completely blank and not performed on previous dates in order to delete a Treatment

• Click the Trash Can icon on the right of the Treatment row to remove a Treatment that was entered in error

Home Exercise Program Tab

• Enter any notes you have for the patient pertaining to any assigned home exercise program

Billing Review & Signature Tab

• In this section you'll be able to add Insurance-Paid Treatments, Self-Paid Treatments, and Supply Charges.

**Note: If the patient is marked as Self Pay, only the Self-Paid Charges table will show. 

• Enter the Visit Based and Time Based treatments to be billed to insurance
  • CPT codes from the POC or latest visit will auto-populate. If any of the treatments do not apply to this visit, either enter 0 in the minute field, OR delete the treatment by clicking the trash can icon (The treatment can be re-entered on a following visit if needed)
    • A T or V will show next to the CPT code listed to advise if this is a time based treatment or visit based treatment

• Enter Treatment Minutes in the Minutes column of the charge table for the CPT Code.
• Units will be auto generated based on the number of Minutes entered for the CPT Code per the insurance guidelines the payer follows.
• Mark a charge Concurrent by clicking the check box in the Concurrent column of the charge table. 
• Mark a charge No Charge by clicking the check box in the NC column of the charge table.
• Modifiers should auto apply based on the modifier rules built for the insurance. 
  • For any CPT's added to the visit the Modifier will be auto applied to the added code once the note has been signed by the therapist.

Adding CPT Codes to the Charges Table

• Click in the drop-down menu in the CPT Code column of the Charge table

• Click on the CPT Code that needs to be added to the Charge table

Adding and Removing Diagnosis Codes

Removing a Diagnosis Code

• Click the X next to the Diagnosis code to remove the diagnosis from the case

• Click in the drop-down menu in the Diagnosis Codes column of the Charge table to the right of the CPT Code

• Click the check box next to the Diagnosis code to remove that diagnosis code from the CPT

Adding a Diagnosis Code

• Click the + icon to add a Diagnosis code to the case

• Type the Diagnosis code or the Diagnosis code description in the Keyword Search box in the Select Code for Additional Diagnosis pop up

• Click the Arrow icon to the left of the description to expand the Diagnosis list. Keep clicking the arrows to expand the list options until you see a blue underlined Diagnosis code

• Click the blue underlined Diagnosis code you would like to add to the case
• This will bring up an Instructional Notes box to populate within the Select Code for Additional Diagnosis pop up menu

• Click the Use this Code button to add the diagnosis code to the case

Adding a Self-Paid Treatment

Adding a self-paid treatment when billing insurance

• Click the Add Self-Paid Treatment button below the Insurance Charge table. 

• This will create a Self-Paid charges table below the Insurance Charge table. 
• Click in the drop-down menu in the CPT Code column of the Charge table
• Click on the CPT Code that needs to be added to the Charge table

• Enter the Total Time spent with the patient for the visit. (This should include the Insurance-Paid charge minutes and the Self-Paid charge minutes.) This cannot be less than the total minutes listed in the Charges table at the bottom of the minutes column.  

Adding and Removing Supplies

• Enter the Supply Code in the Supplies charge table
• Enter the Quantity of the supply under the Qty column
• Click the check box in the Pt column to bill the supply to the patient
• Enter any Modifiers under the Modifier header
• Click in the Diagnosis Code drop-down menu to remove Diagnosis Codes from the supply
  • Click the check box next to the Diagnosis in the drop-down menu to remove the Diagnosis Code from the Supply
• Click the Trash Can icon to the right to remove the supply if added in error

Sign the Daily Note

• Carefully review the note! Remember, it will be locked and un-editable once you sign it.
• Enter your 4 digit PIN, then click Sign and Submit.
• If an assistant signed the Daily Note:
  • The note will be locked/ un-editable for the assistant and placed in the clinician Work Queue for a co-signature.
  • The selected clinician will be able to open, edit, and co-sign the note.

Note: If the note is not yet complete, click the Save Changes button and return later to finish it.