Creating the Initial Eval

AgileEMR - Creating the Initial Eval

The Initial Evaluation feature allows a user to fill out a detailed SOAP evaluation for the patient electronically as well as generate a Plan of Care document after completing the document.  

Due to the large amount of information included in this document, it has been split up into sections:

• Header
• Subjective
• Objective
• Assessment
• Treatment
• Plan
• Diagnosis
• Signature

**The additional sub-categories of this document will explain each section mentioned above in detail.

In order to aide in efficiency and thoroughness of documentation for the Clinician, the Initial Evaluation features include: 

• Ability to flag Subjective and Objective measures as problems to easily build a Problem & Goal list 

**Note: Only flagged items will pull to the PDF version of the Initial Plan of Care.

• Templated Based sections for Subjective, Objective, Assessment and Treatment Plan information
• Auto-calculation of Goal Percent for Quantitative Based Problems on Progress Notes and Discharge Summaries
• Generation of both the Initial Evaluation and Plan of Care PDFs
• Auto filling the first Daily Note SOAP with “See Plan of Care” text 
• Ability to “Re-open” the documents with PDF Versioning to allow for easy correction of mistakes
• Compliance Validation by Section with visibility into required fields for audit-approved documentation

Create/Open Initial Evaluation Document

Upon patient appointment check-in via Schedule, a Create Document task for Initial Evaluation will display in your Work Queue.

**Note: Items that are Flagged in Initial Evaluation to pull forward is what will be displayed on Plan of Care PDF.

You can access the document in the following ways:

• Work Queue

  • Click on the Work Queue header name in the Top Navigation Panel

    

  • Find the Initial Evaluation task and click on Create

    

• Case Work Queue

  • Search for the Case in the Case Search area

    

  • Open the Case and click on the Documentation Tab in the Case Navigation Panel on the left. 

    

  • Under Therapist Tasks, you will see the Create Document task for the Initial Evaluation. Click on Create Document.

    

• Schedule

  • Navigate to the Schedule by clicking Schedule in the header section of AgileRPM.

    

  • Click on the Appointment

    

  • Click on Documentation

    

  • This will bring you into the Documentation Tab of the patient's case where you will then click on Create Document for the Initial Evaluation under the Therapist Tasks header.

    

Basic Document Navigation

After opening the Initial Evaluation, you will notice that the entire document has been divided into sections.

The sections are as follows: 

• Header
• Subjective
• Objective
• Assessment
• Treatment
• Plan
• Diagnosis

• Signature

  

Header Section Overview

The first part of this section provides the following information: 

• Date of Eval- First Appointment of the case
• Patient Name, Date of Birth, and Age

• Therapist- Assigned therapist that's performing the Initial Eval.

  

The second portion of the header provider Referral Information. Information changed or added to this section will be communicated back to the Referral Tab of the case. 

• Referring Physician- may be changed or updated by typing in the field

  • Additional Physicians- may be added by pressing the + icon

    

• Next Physician Appointment- This is an optional date field that the user may use to have the Next Physician Appointment information included on the future Daily Notes.

  

• Self-referral checkbox if checked, will mark that the patient is as a self-referred patient. 

• Referring Physician Diagnosis pulls from the Referral Tab and will reflect what information was placed there from the script. 

  

The third portion of the Header is used for the assignment of a Template across the document. Templates will be discussed in more detail later in this document. The information used is: 

• Body Region- Pulls from the Referral Tab but may be changed
• Orientation- Pulls from the Referral Tab but may be changed

• Template- Defaults to Corporate Template but may be changed by the user to a Personal Template. 

  

Completing the Subjective Section

The Subjective section is sub-categorized in the following areas: 

• Reason for treatment
• Prior level of function
• Current level of function
• Functional problems
• Pain assessment
• Patient concerns
• Medical history
• Personal information

1. Reason for Treatment provides an area to give a high-level overview as to why the patient is being seen for treatment. 

*Denotes a required piece of information

• Condition Type*
• Date of Onset*
• Acute/ Sub-Acute/ Chronic
• Prior Treatments*
• Prior Tests*
• Mechanical Stresses & Symptoms
• Mechanical History & Review
• Bladder & Bowel 

• Voice & Speech

  

A user must select a Condition Type for the patient from the choices of Insidious, Injury, Post Surgical, and Other.

• Depending on which type is selected the Corresponding Free Text Areas will display underneath. The fields highlighted in Red are required items. Please see below. 

  

  

  

  

Date of Onset may be pulled from the Referral Tab if this information has been entered in during the case setup.

• This date can be

  • Type the Date of Onset using the keyboard

    

  • Select a Date of Onset from the Calendar

    

Updates to the Date of Onset will be communicated back into the Referral Tab and updated accordingly.

• Acute- Pain goes away
• Sub-Acute- Pain comes and goes
• Chronic- Pain is constant and unbearable

• If YES, the system will display a list of Prior Treatments/ Prior Tests from which the user may select applicable items. 

  

  

• If a choice is missing from the list, you may select Other and type the name in the free text box provided. 

  

• There are also Prior Treatment Notes and Prior Test Notes sections provided at the bottom of each section as well. 

  

  

• To enter a

  • Type in the provided Prior Functional Limitation Notes Free Text Area 

    

  • Select from a drop down of commonly used terminology to describe the functional limitation of the patient.

    

• Selected drop down items will be pulled down into the Prior Functional Limitations Notes Free Text Area and may be edited. 

  

3. Current Level of Function provides an area to report the Current Level of Function for the patient through Self Assessed Function or Scales.

By default, a common Self Assessed Functional Scale will display depending on the Body Region selected in the Initial Evaluation Header. 

• This may be changed by selecting a Different Scale from the drop down menu.

  

• Choosing the Other option in the drop down menu will allow you to name and enter your own.

  

Complete the Current Level of Function requirements by: 

• Enter the Score that the patient reported on the Selected Self Assessed Function Scale.

  

• The system will auto-calculate the patient's Current % Limitation below based on the Selected Self Assessed Function Scale Equation.

  

• Enter a Goal % Limitation for the patient in the field provided. 

  

• Users may add additional scales by selecting a scale and clicking on the Add Scale button.

  

• The additional function scale will be added with corresponding Score and Goal % Limitation fields for that patient. 

  

• If you would like to track functional gain for a patient with the Self Assessed Functional Scale that you have added. You may do so by clicking on the Flag button next to the Scale.

  

• This flagged scale will be added to the Quantitative Objective Findings Table in the Assessment section to be tracked throughout the duration of care for the patient. 

4. Functional Problems provides an area for listing the subjectively reported functional problems of the patient. This is the ONLY portion of the Subjective section that is fully Template Based. 

**Note: At least ONE functional problem is required. (to bypass this type N/A or (-) into the section)

• To add a Subjective Reported Functional Problem simply type in the available Functional Problem Free Text Field. 

  

• As you type, an additional Functional Problem Free Text Field will populate below. You may add as many problems as you'd like.

  

• Below is an example of what a Templated Functional Problems List might look like for a Shoulder Template. If used to to fill out this section you would only need to modify, edit, or delete problems per the current patient's needs. 

  

• To include Functional Problems in the Narrative Problems List of the Assessment section, flag the problem by clicking on the Flag icon.

  

**Note: These items may be edited and have goals assigned to them within the Assessment section. If a template is used, goals may already be assigned requiring only slight modification.

5. Pain Assessment provides an area to communicate the following: 

*Denotes a required piece of information

• Subjective Pain Assessment with Activity*
• Subjective Pain Assessment at Rest* 
• Subjective Pain Assessment Range
• Pain Description
• Pain Location
• Pain Aggravating Factors
• Pain Alleviating Factors

• Create Pain Diagrams

  

Assign Subjective Pain Assessment with Activity and Subjective Pain Assessment at Rest by clicking on the appropriate pain value on the 0 to 10 scale.

• Subjective Pain Assessment is measured so that a score of 0 is no pain and a score of 10 is the worst pain imaginable. 

  

• If you wish to track one of these

  • It will then be added to the Quantitative Objective Findings Table in the Assessment section

    

A Subjective Pain Assessment Range may be assigned by:

• Clicking and dragging from the Lowest Value on the 0 to 10 scale to the Highest Value for that patient's reported range.

  

A Pain Description may be reported for the patient by: 

• Selecting all that apply in the Pain Description drop down menu.

  

• You may also assign a Custom Pain Description by: 
  • Selecting Custom in the Pain Description drop down menu

  • A Pain Description Free Text area will display for you to fill out

    

A Pain Location may be reported by: 

• Typing in the Location Free Text Field provided

  

You may elect to create a Pain Diagram by: 

• Pressing on the Create Pain Diagram button

  

A Pain Diagram pop up will appear on your screen

• Select the Pain Type from the Pain Legend

  

• Click on the corresponding Pain Location on the Pain Diagram Image

  

• To remove/ edit click on the Remove button in the Pain Legend

  

• Then click on the items you wish to remove in the Pain Diagram Image

  

• To add Additional Pain Notes to the Pain Diagram type in the Additional Pain Notes Free Text area provided

  

• To save click on the Save button located at the bottom of the Pain Diagram

  

• You will know that the Pain Diagram was saved because the Create Pain Diagram button will now show as Edit Pain Diagram

  

In this area you will be able to: 

• Save as a new Template- Save template based information as a New Personal Template
• Update Template- Update the current template
• Save Changes- Save the section quickly if you need to leave the document
• Next Section- Saves the current section and opens the next section to proceed with filling out the document

6. Patient Concerns provides an area for users to list a patient's chief complaints or concerns. Patient Concerns are NOT Required to be filled out.

• To add a concern simply type in the provided Patient Concern Free Text area. As the Patient Concern Free Text area is completed an additional Patient Concern Free Text area will populate below for any additional concerns. 

  

• If a concern should be added to the

  • Flagging the item will pull the typed text into the Narrative Problems List for the patient.

    

7. Medical History provides an area to fill out: 

*Denotes a required piece of information

• Medications*
• Past Surgery*
• Comorbidities/ Precautions*
• Fall History
• Drug History

• Additional Medical History Notes

  

Enter and fill out the required information for Medications by: 

• Answer

  • If Yes is selected, either fill out the Medications Free Text area or check the See Medication List checkbox

    

  • If No is selected, nothing will display to be filled out

    

Enter and fill out the required information for Past Surgery by:

• Answer

  • If Yes is selected, either fill out the Past Surgery Free Text area or check the See Surgery List checkbox

    

  • If No is selected, nothing will display to be filled out

    

Enter and fill out the required information for Comorbidities/ Precautions by:

• Selecting None or at least one comorbidity or precaution from the list: 

  

8. Personal Information provides an area to fill out:

**Note: Nothing is required in this section. It's completely optional. 

• Occupation
• Job Duties
• General Activity
• Hobby/ Interest
• Work Status & Restrictions
• Living Situation
• Dietary Considerations
• Learning Styles & Readiness
• Psychosocial Considerations

• Cognition & Mentation

  

As you may have noticed, a few commonly reported items such as Occupation, Job Duties, General Activity, and Hobby/ Interests will display by default for easy entry. 

• To provide Other Personal Information you can do so by pressing the + icon in that section. Please see example below with Work Status & Restrictions.

  

• The corresponding Work Status & Restrictions section will open providing additional fields to enter information.

  

Completing the Objective Setting

The Objective section is sub-categorized in the following areas:

• Observation
• Range of Motion
• Strength
• Neurological
• Joint Mobility
• Flexibility
• Palpation
• Special Tests

Sub-Categories are provided to organize the information for your Templates. 

• Each section can be opened by pressing the Expand arrow for that section. 

  

Each section works similar in fashion, each sub-category allows you to perform the following tasks as you fill out a current Initial Evaluation OR when you are building your templates:

• Create Measurements
• Create Tables
• Create Structured Range of Motion/ Strength Tables (Only available in Strength and ROM categories)
• Flag issues as Problems
• Write Section Based Problems
• Add Section Based Comments

In the following pages we will go over how to preform these tasks and provide an example of what a section might look like with a template. 

• Select the Data Type of Create Measurement

  

• Assign a Label in the Enter Label Free Text Field for the measurement you wish to create.

  

• Select

  • Number- a numeric free text area with an option to include a label. You may also assign an orientation if applicable to report on only right, left, or both sides. 

    

  • Multiple Choice- a list of preset choices displays for your measurement to make for easy assignment. You may also assign an orientation if applicable to report on only right, left or, both sides.

    

  • Free Text- have a Free Text area included for the measurement

    

• You may choose one or multiple element types to include for your measurement. Below is an example that used ALL the available element types. 

  

• Click the Add button to create the measurement

  

• The Measurement will display below. If added, only one of the elements is required to be filled out to fulfill the validation. 

  

• To include the findings from this measurement in the Narrative Problems List of the Assessment section click on the Flag icon.

  

**Note: Only flagged items will pull to the PDF version of the Initial Plan of Care.

• Select the Data Type of Create Table

  

• Enter a title for the table in the Enter Title Free Text area provided.

  

• Enter the Column Amount needed for the table. Rows will be added AFTER table creation. 

  

• Click the Add button to create the table.

  

• The Table will be added below. You will need to assign Column Titles and add some applicable rows by pressing the + icon on the Last Row.

  

**Note: By keeping row information generic, you can use the tables as Templates and then fill out accordingly for a Initial Evaluation. Please see the example below.

Strength and Range of Motion sub-categories have an additional feature called a Structure Table.

• The Structured Table has a set of Predefined Measurements in the database for easy addition. 
• Measurements included in the Structure Table may be tracked throughout the duration of care under the Objective Findings Table in the Assessment of the Initial Evaluation and future Progress Notes/ Discharge Summary documents. 
• Goals will be assigned to these values in the Assessment section and will auto-calculate Goal Percent on Progress Notes/ Discharge Summary documents. 

Structure Tables for Strength and Range of Motion will display by default (unless a Template is used)

• The primary Body Region will pull from the Header of the Initial Evaluation document.

  

• Select the Measurements from the drop down menu for that Body Region. Select ALL that apply. 

  

• Click on the Add button to add the Selected Measurements.

  

• The Selected Measurements will display in the Structured Table.

  

Add another Body Region Structured Table by: 

• Selecting the New Body Region in the Primary Structured Table.

  

• Select the Measurements from the drop down menu for that Body Region. Select ALL that apply. 

  

• Click on the Add button to add the Selected Measurements. 

  

• An Additional Structure Table for that Body Region will be added below the Primary Structure Table. 

  

**Note: Structured Tables may be saved to Template as well so that Common Measurements display by default. You will only need to edit/ modify as necessary for that patient.

If you want to track a Structure Table Measurement throughout the duration of care: 

• Flag the measure by clicking on the Flag icon next to it. This will be added to the Objective Findings Table in the Assessment section to be tracked on future documents. 

  

Section Based Problems are available for you to write narrative problems for that section by: 

• Typing in the Free Text Field provided in each sub-category.

  

• Section Based Problems

  • To unflag, click on the Flag icon to remove it from the list. 

    

**Note: As mentioned before, everything in the Objective section can be included on your Template. 

• Section Based Problems are a great area to include basic Narrative Problems so that you may assign Goals within the Assessment section prior to filling out the Initial Evaluation.
• This increases efficiency by allowing you to only have to edit/ modify information as necessary.

Additional Comments by section may be entered by: 

• Typing in the Additional Comments Free Text area provided at the bottom of all sub-categories.

  

Completing the Assessment Section

*Denotes a required piece of information

The Assessment section provides an area for: 

• Objective Findings
• Narrative Problems List*
• Narrative Goals List*
• Rehab Potential*

• Therapist Assessment*

  

This section was built in such a way so that if you have flagged information from the Subjective and Objective sections these will be pulled down in the Objective Findings Table or Narrative Problems List. 

The Objective Findings Table provides an area for quantitative values that may be tracked throughout a Case in order to provide numerical evidence of functional gain over time.

• These Measurements will require that specific Goal Measurement be added for this table as well as an Achieve Within time frame. 

  

• If Measurements are Flagged in a Template, the Goal Measurement and Achieve Within time frame could be filled out and already fulfilled prior to opening a new Initial Evaluation. Then you would only modify as needed for the patient.

  

**Note: Any values added to this table will allow for the auto calculation of Goal Percentage in future Progress Notes/ Discharge Summary documents allowing you to save time on documentation.

• Objective Findings must be added via Flag from the Subjective and Objective sections above. However, you will be able to Delete any items for the patient using the Trash icon on each row. 

  

The Narrative Problems and Goals List Table provides an area for written-based problems and goals for the patient. This section may be filled out via template and only require modifications as necessary per patient. 

The Validation Requirements of this section are:

• At least one Problem and one Goal are included for the Initial Evaluation. However, you may have more Problems than Goals or vice versa. 

• If a Goal has been assigned, an Achieve Within time frame has been assigned as well. 

  

Completing the Treatment Section

*Denotes a required piece of information

The Treatment section provides an area for: 

• CPT Code Assignment*
• CPT Code Description

• Free-Forms Descriptions of Treatment*

  

The Treatment section can be fully templated or Additional Treatments may be added to the list.

• To add a Treatment to the list, type the CPT Code, Charge Code, or CPT Description in the Treatment Selection Box and select one.

  

• The Added Treatment will display at the bottom and require that you fill out a Free-Form Description for that code. 

  

**Note: You may Add or Remove as many treatments as necessary for the case. All treatments will be included on future Daily Notes for time and Unit Assignment. 

Completing the Plan Section

*Denotes a required piece of information

The Plan section provides an area for: 

• Total Visits*
• Frequency and Duration* 

• Recommendations

  

Enter a Total Visit amount for the total number of visits you plan to see the patient for this case.

Completing the Diagnosis Section

*Denotes a required piece of information

The Diagnosis section provides an area for: 

• Primary Treating ICD-10 Diagnosis*
• Additional Treating ICD-10 Diagnosis Codes
• External Cause Codes

• Coding Assistance & Communication

  

Select the ICD-10 Code you wish to use, Complete ICD-10 Codes will display in blue. 

• Click on the Use this Code button to use it. 

  

The added Primary Testing Diagnosis Code will display. 

• You may add Additional Treating Diagnosis Codes and External Cause Codes as necessary using the same process as described above.

  

• You may also provide additional
  • Clicking on the + icon on the Coding Communication & Assistance section

  • There are no required elements for this section

    

    

Completing the Signature Section

*Denotes a required piece of information. *All Components are Required

The Signature section provides an area for: 

• Preview Plan of Care Document*
• Patient Agreement Statement*
• PIN- Electronic Signature of Document*

Complete the Patient Agreement requirement by checking on the Patient Agreement Statement checkbox

Preview the Plan of Care PDF by clicking on the Preview Plan of Care button.

The Plan of Care PDF will display in a separate tab for you to review.

Enter your personal 4-Digit PIN and click on the Sign and Submit button to electronically sign and submit the document. 

**Note: Upon Signing, the Plan of Care PDF will be sent to the Front Office Admin Work Queue to be faxed to the Referring Physician.

Printing the Plan of Care PDF

You may print the Plan of Care by: 

• Clicking on the PDF Icon under the Signed Documents heading on the Documentation Tab of the case.

  

• Clicking on the Case Files Tab within a case.