Completing an Updated Plan of Care

Completing an Updated Plan of Care

Schedule:

You'll notice a POC or a PN next to the patient's appointment time on the schedule if an Updated Plan of Care/ Progress Note is due.

  • This task will be Red if the Plan of Care or Progress Note is Expired
  • This task will be Yellow if the Plan of Care or Progress Note is Expiring

To Create the document for the Updated Plan of Care:

  • Open the patient's case
  • Go to the Documentation tab
  • Under the Therapist Tasks header you'll see an Expired/ Expiring Plan of Care task

  • Click on the Update POC or DS button under the Action header

  • You'll then see a Choose Action pop up window. This will allow you to: 
    • Request more visits in a Progress Note and continue treatment
    • Discharge the Patient

  • Select the Request more visits in a Progress Note and continue treatment option
  • Click OK
  • This will open/ create a Progress Note task under the Therapist Tasks header in the Documentation tab and pull you into the Progress Note
  • In the Progress Note header you'll see: 
    • Patient Name & Date of Birth
    • The Date you are creating the Progress Note
    • Referring Physician
    • Attended Visits & Cancellations
    • Diagnosis
    • Precautions

  • The Progress Note is broken down into the following sections: 
    • Treatment
    • Subjective
    • Problems/ Goals List
    • Assessment
    • Treatment Plan
    • Plan of Care Status, Frequency and Duration, Recommendations
    • Signature

Treatment

  • Under the Treatment section you'll see:
    • First Visit
    • Most Recent Visit
    • Summary of CPT's billed thus far
    • Comments (optional)

Subjective

  • In the Subjective section you will enter the patient's Chief Complaint(s)

Problems/ Goals List

  • In the Problems/ Goals List you can enter measurements for:
    • Objective Findings
    • Problem & Goal Descriptions
Objective Findings
  • The Objective Findings measurements are broken down into 5 categories: 
    • Initial measurement
    • Current measurement
    • Goal measurement
    • Goal Percent (auto-calculated from current measurement vs. goal measurement)
    • Notes

  • You can flag any of the Objective Findings by clicking on the Flag button next to the Objective Finding
  • When the flag is Green the Objective Finding will carry forward for future monitoring
    • To stop the Objective Finding from pulling forward, click the Flag button so it's no longer Green

To Add a New Measurement: 

  • Click on Add New Measurement at the bottom left of the Problem/ Goals List section

  • You'll then see the Add Measurement pop up window

  • Select the appropriate: 
    • Body Region
    • Select Category (Type of Measurement) 
    • Range of Motion
    • Strength
  • Click Add Measurement

  • You'll then see that New Measurement added to the Objective Findings table under the Problems/ Goals List section
  • You will be required to fill in:
    • Current measurement
    • Goal Measurement
    • Number of weeks for this Problem/ Goal to be completed
    • Enter any additional notes in the Notes free text field
Problems & Goals Descriptions
  • The Problems & Goals Descriptions is broken down into 4 categories: 
    • Problem Description
    • Goal Description
    • Goal Percent 
    • Note

  • The Problem Description column and Goal Description column are free text fields
  • In Problem Description column note a brief description of the patient's problem(s)
  • In Goal Description column note a brief description of the Goal for the patient as it relates to the problem to the left
  • In Goal Percent select the percentage the patient is currently at as it relates to the problem to the left
  • Enter any additional notes in the Notes free text field

  • You can flag any of the Problems/ Goals by clicking on the Flag button next to the Problem/ Goal
  • When the flag is Green the Problem/ Goal will be carried forward for future monitoring
    • To stop the Problem/ Goal from pulling forward, click the Flag button so it's no longer Green

  • To remove a Problem/ Goal from carrying forward, click the Flag button so it's no longer Green.
  • To add a new Problem/ Goal to the list you can type in the Problem/ Goal Description free text field at the bottom of the Problem/ Goal Description table

  • Enter the Problem in the Problem Description free text field
  • Enter the Goal in the Goal Description free text field
  • Enter the Number of Weeks you'd like the patient to reach the Goal in

  • A new free text field will populate once the new Problem/ Goal is added

Assessment

**NOTE: All fields are required

  • In the Assessment section you'll enter: 
    • Rehab Potential
    • Therapist Assessment

  • Select the most appropriate Rehab Potential for the patient from the drop-down menu
  • Enter a Therapist Assessment of the patent in the free text field

Treatment Plan

  • In the Treatment Plan section you will review any CPT codes that have been billed for the patient
  • To show the most common CPT codes click on Show most common CPT codes in the header of the Treatment section

  • To Delete a CPT code, click the trash can icon to the right of Treatment Details

  • To Add a CPT code, select the new CPT code from the drop-down menu (to easily find the code, start typing the code in the drop-down menu)

Plan of Care Status, Frequency and Duration, Recommendations

In the Plan of Care Status, Frequency and Duration, Recommendations section you can: 

  • View the Current Plan of Care Status
  • Update the Plan of Care Status
  • Select Frequency and Duration of treatment
  • Place the patient on hold
  • Add additional recommendations 

To View the Current Plan of Care Status: 

To Update the Plan of Care Status: 

**Note: You'll only be able to ' Continue with the Current Plan of Care' if there is enough visits and weeks left based on the last Plan of Care

In the example below you'll notice there are 5 visits remaining under the 'Current Plan of Care' but there are no more weeks left. Additional weeks will need to be requested for this patient to continue treatment.

  • Click the Update Plan of Care, I need __ visits in addition to the number remaining and __ more weeks

  • Enter additional Visits needed in the Visits field

  • Enter the number of additional Weeks or Months needed from the drop down menu (click in the Weeks drop-down menu to switch to Months)
  • Updates to Visits and Weeks will show in the table to the right 

  • Enter Frequency and Duration by clicking on the Pencil and Paper icon under the Frequency and Duration header

  • You'll then see the Edit Frequency and Duration pop up window

**NOTE: This is for informational purposes only and does not affect the number of planned visits

  • Select the Frequency of visits for the patient. 
    • The Duration will auto populate based on how many weeks are left/ how many weeks were requested for the patient
  • Click Save

  • You'll see the Frequency entered appear under the Frequency and Duration header after clicking Save

  • Enter any Additional Recommendations in the Additional Recommendations box

Signature

In the Signature section:

  • Click the checkbox next to 'I certify the need for these medically necessary services to be furnished under this plan of treatment from 12/21/2020 to 1/18/2021 and while under my care.'

  • Enter your 4-digit PIN 
  • Click Sign and Submit

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