Lesson 3 Comprehensive Documentation IPED Documentation PT & OT

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1 Lesson 3 Comprehensive Documentation IPED Documentation PT & OT

2 Evaluation All evaluations start by choosing a patient from your schedule as outlined in the Introduction Chapter. Refer to the Introduction before reading this chapter. The initial evaluation chapter details the entirety of screens and options available in IPED. The order of screens may be different based upon your organizations choice of workflow design. All tabs shown in the manual may not be utilized within your organization and reflect the organizations choice for documentation of each note type. User discretion is appropriate within documentation while still meeting payer documentation requirements. MedAdept defers to your organization for their specific requirements and any clarifications you may need. Visit Type Screen The Visit type drop down menu allows therapist to change the type of note at any time. For Initial Evaluations visit type is E. If visit type is something other than E, the New Type category is used to change visit type to E for evaluation. Location should also be appropriate to your discipline or body part depending on your organizations set up choices. If this is not populated or is not appropriate for the patient, use the drop down menu in New Location category to update this to desired option then tap Set New Location to save. This will be the first screen you return to after selecting a patient note that is incomplete to finish. Tap >> or Menu to advance to next screen.

3 Billing Information Screen The Billing Information Screen provides parameters entered into RM6. On this screen you must choose the Dx Select tab in order to move forward. On Billing Alerts screen, you will see any visit limits, progress toward cap in Medicare Part B, visit limits, etc. Billing Information- Dates Screen In the Dates screen, the top row of data is carried over from RM6 to the IPED, it includes referral date, Admit Date, Script Renew and Recert Due dates. The next 2 lines of dates can be modified or changed on the handheld, those include surgery date, onset date, MD return date and Recert date. Notice that the surgery date is 01/01/1900, this is the default date if no data is entered and is equivocal to be not applicable.

4 Diagnosis Select Screen In Dx Select tab utilize the scroll down bar to arrive at the Location that correlates to therapists discipline: PT, OT, Cognitive, Speech, or Swallow. Depending upon how your organization set up the system there may be other choices associated with body parts. Then tap on the desired choice and Select Dx for Treatment, followed by >> to advance screen. Subjective Chief Complaint (CC) Screen Affected Side must be chosen at the time of the evaluation by tapping next to the appropriate radio button. Chief Complaints can be multiple selected by tapping (highlighted) on appropriate items, this is a multiple select menu indicating more than one item may be chosen and once all appropriate selections are made tap Set Subjective/CC to save. To unselect an item, simply tap on it again. **Do not set individually tap Set Subjective/CC on each item, this creates multiple duplicates and is a common mistake for beginning users. Utilize the Review tab to ensure you have chosen only the items you intended to and there are no duplicates. If duplicates or incorrect entries are found, those items can be deleted on this screen. As you become more comfortable and familiar with the system, you will not necessarily need to utilize Review as often.

5 Subjective Function Screen PLF Builder- Documentation of prior level of function. Tap on PLF Builder and you will be taken to the following screen that allows therapist to build a statement related to prior functional status. Statements are built using date of prior status, level of assistance, with given activity, and assistive device. Scroll bar on far right of screen is used to access all information on screen. The drop down menu allows multiple choices for each category, if a category does not apply or you chose not to document on it, choose N/A. If you need to provide additional individualized information, choose free text to allow entry of a unique item for the patient. Once complete, tap Build at far bottom right corner. Prior level of function statement is then displayed and you are prompted to tap Yes to save.

6 Complete this process on as many items as are appropriate then tap Close on bottom left to leave this screen and return to Function Screen seen below. CLF Builder- Documentation of current level of function. Tap CLF Builder and you will be taken to the following screen that allows therapist to build a statement related to change in functional status, related to what precipitating event and related to not what factors impact recovery. Scroll bar on far right of screen is used to access all information on screen. The drop down menu allows multiple choices for each category, if a category does not apply or you chose not to document on it, choose N/A. If you need to provide additional individualized information, choose free text to allow entry of a unique item for the patient. Once complete, tap Build at far bottom right corner.

7 Current level of function statement is then displayed and you are prompted to tap Yes to save. Complete this process on as many items as are appropriate and tap Close on bottom left to leave this screen. Subjective Pain Screen If patient has no pain, simply tap the box for Patient reports no pain. Location is where the specific body part or region of pain if recorded. When you tap in the text box a virtual keyboard will pop up. Pain rating of 0-10 Pain scale can be recorded at Rest, Least, and Greatest. Pain Type contains adjectives to describe the pain, tap items to highlight. This is a multiple select menu. Pain Relief contains items that alleviate the pain, tap items to highlight. This is also a multiple select menu. Tap Set Pain Results to save data. All items are not required to be populated, only information that is appropriate to that patient.

8 Subjective Home/DC Environment Screen Documentation of Home/DC Environment includes documentation of handrails, stairs, rug, equipment, etc at Entry, Bath/BR/Kitchen, Social Support and Barriers. Multiple select as many items as are appropriate and tap Set Home Assessment to save data. Subjective Review Screen The Review tab allows you to see items that you documented during the evaluation and review for accuracy of input. Tap on the radio button for each section of the subjective portion of the note to display items for each tab. Use of this tab is invaluable in the early stages of implementation to ensure that you saved data, to delete incorrect or multiple entries or to reorient yourself to what was input if you are interrupted or are working with multiple patients. The bottom row of items is also available to be accessed on most screens. Comments can be added to include greater detail or to document information specific to this patient that does not fit into the subjective categories that have been covered. This information can be entered via keyboard, dictation ( if your organization chose to utilize this feature), or via desktop after completion of your evaluation on the IPED. Once you have reviewed data, tab >> to advance to next screen.

9 Comments Supplemental information can be entered into the document via this screen two ways. For either method, you must first indicate what section of the document (Subjective, Objective, Assessment, or Plan) you want the supplemental information to appear in at the top of the screen. This is done by tapping the appropriate radio button. Information can be entered by following one of these procedures: 1. Tap in the large white space to activate a keyboard. Using your stylus and the keyboard, you can type short statements into the note. Once you have completed typing, tap the keyboard icon located in the bottom right corner of the screen. Then tap the Set Comments button to enter the additional information into the record. This information can be further edited by returning to this screen before completing the entire note and tapping on the Review button, then tapping in the white space adjacent to the content you wish to edit. Make sure the appropriate radio button is selected to find the content you wish to edit. Information entered on this screen can also be edited at a desktop computer once the note has been completed and closed on IPED. 2. If your organization has chosen to utilize the dication component with voice recognition software, tap the Record button and speak clearly into the microphone located on your handheld device. When you have completed dictating your information, tap the Stop button, then tap the Send button. Two messages will appear on the screen verifying that the voice file was sent. Tap the OK button on each of these messages. In 30 to 45 seconds, tap the Review button and your transcribed dictation will appear in the white space. You can edit the transcription by tapping in the white space to activate the keyboard. The transcription can also be edited at a later time by returning to this screen and tapping Review and then activating the keyboard. Transcribed notes may also be edited at a desktop computer once the note has been completed and closed on IPED.

10 You can review additional notes that were added at a prior date by tapping on the Review Previous button. Previously entered notes cannot be edited or altered on IPED. Once you have completed entering additional information, tap Close tab and you will return to the section of the document you left. Tap >> to advance one screen. Precautions Screen Precautions/PMH are determined by surgical procedure, healing time, comorbidities that impact treatment, etc. This is extremely helpful for continuity of care and/or PRN therapists to be aware of protocols and patient precautions/history. Items must be selected one at a time by tapping to highlight then tap Set PMH/Prec. New items can be added by tapping on Create New Patient Alert. A Code is created using the first 3-4 letters of the item name, the entire name is then typed in the Description box, followed by Set. Once items are added, they remain in the library for future patients and are available to all therapists.

11 Vital Signs Vital signs can be documented including: Temperature, Pulse and Respiratory Rates, blood pressure, amount of Oxygen, and Oxygen Saturation. Tap the Radio Button beside the item you wish to document, in this example Temperature, then choose location taken from the drop down menu and at the bottom right enter the temperature and tap Set Temperature to save. This functions the same for each category. Tap >> to advance to next screen.

12 Protocols The protocol screen allows therapists to choose from the protocols associated with disciplines/locations (PT, OT, speech, swallow, knee, shoulder, etc) established by the organization prior to the implementation of IPED. Protocol information is a quick way to access information used to treat common diagnosis. Tap an item to select protocol of your choice(highlight) then Update Current Protocol. Tap >> to advance to next screen.

13 Cognitive Assessment-Impairments Cognitive Assessment Impairments allows for the documentation of cognitive impairments and orientation that may impact treatment, this is a general documentation component for physical and occupational therapy. The evaluations for speech will cover discipline specific items in detail. Cognitive Assessment-Mood/Processing The Mood/Processing assessment allows for the documentation of general presentation, mood, and behavioral impairments that may impact treatment. This is a general documentation component for physical and occupational therapy. The evaluations for speech will cover discipline specific items in detail.

14 Cognitive Assessment-Speech The Speech assessment allows for the documentation of general speech impairments that may impact treatment. This is a general documentation component for physical and occupational therapy. The evaluations for speech will cover discipline specific items in detail. Tap >> to advance to next screen. Range Of Motion/Flexibility Per Protocol Screen This tab contains quick access to the items established in the protocol as those most commonly recorded for this diagnosis. Tap on desired item to highlight (Hip ROM) then tap appropriate box for Left and/or Right for Within Normal Limits(WNL), Not Tested (NT), or tap in empty text box and enter information in desired format (90 degrees, 50%, etc). Text Box is limited to 10 characters, if this is exceeded you will receive a Truncated error. Tap Set ROM to save. Use Review Selections tab to review data input for accuracy or delete duplicates or incorrect entries. This is especially helpful early in training. Tap >> to advance to next screen.

15 Range Of Motion/Flexibility Optional Screen The Optional tab details additional movements or surrounding joints, and is available if more information than is in Per Protocol tab needs to be recorded. A/PROM is indicated by tapping appropriate radio button. Tap appropriate box for Left and/or Right for Within Normal Limits(WNL), Not Tested(NT), or tap empty text box to fill in data in desired format (90 degrees, 50%,etc). Text box is limited to 10 characters. Tap Set ROM to save. Use Review Selections to ensure accuracy of data. Record of data entry may also be deleted in review selections tab. Tap to highlight appropriate record then tap Delete Record to remove. Tap >> to advance to next screen.

16 Muscle Strength Screen The Per Protocol tab is populated by Muscles, Muscle Groups, and/or Screens. Tap to highlight appropriate items that are of the same grade. Record strength grade in desired format (4/5, 50%, WNL, WFL, etc.) in Left and/or Right text box as appropriate for patient. Tap Set Score to save. Tap Set CPT box if your organization uses this code when performing total body strength testing. Optional follows same format for surrounding joints or areas that need to be recorded, and Review selections for accuracy of data entry or to delete items. Tap >> to advance to next screen. Miscellaneous Measurements/Special Tests Screen Special tests allows recording of results for appropriate areas, in this case Berg Balance and Tinetti related to gait. Tap on name of test to highlight then tap in text box for Left, Right, or No Side Assigned to record score. Tap Set Special Test to save data. Review Selections can be used to review for accuracy or to delete a record.

17 *Gait Assessment Evaluation Screen *OT s will not see the Gait Assessment Screens in their workflow. They will see Functional Assessment Screen next. Drop down menus are available to document surface, level of assistance, assistive device, distance ambulated and minutes. These minutes do not count toward PPS minutes are they are evaluative in nature. Once parameters are set tap Set Gait to save. To access remaining tabs at bottom of screen simply tap on desired screen to show information. Gait Assessment Goals Screen Goals can be established for Gait for Independence and Assistive Device which can be chosen from drop down menu and for Distance which can be added in free text via virtual keyboard. Once these parameters are established, tap Set Gait Goals.

18 Gait Assessment Deviations Screen Gait Deviations are documented by tapping to highlight as many items as are appropriate. Utilize the scroll bar to view all deviations, then tap Set Deviations. If you are unable to find a particular item on the list, you can utilize Comments tap to free text in notes on deviations observed. Review tab will allow you to see the information you have entered for these tabs. Tap >> to advance screens. Functional Assessment Previous Level Screen **Upon evaluation this screen will be empty as no prior data has been entered. In future notes (recerts, progress notes, Discharges) previously entered data will display. These items may then be updated by tapping to highlight chosen item then tap Select Item. Then enter current Score via drop down menu then tap Set Level to save.

19 Functional Assessment Functional Screen Functional Screen allows documentation of a variety of functional activities including bed mobility, toileting, dressing, bathing, etc. Utilize the scroll down bar to view entire list. Tap items to highlight, if multiple items have the same current level, you can multiple select those items at the same time. Then tap Set Functional to save data. The components box further breaks down items into their component parts and documents levels of assist for activities such as rolling, etc. Tap next to Other to allow free texting of Current Level results if needed. Tap >> to advance screens. The Review tab allows reviewing of data entered for accuracy and to delete duplicates or entries made in error. Tap >> to advance screen.

20 Interventions Previous Screen **Upon evaluation this screen will be empty as no prior data has been entered. However at future appointments, it will be populated. Interventions Protocol Screen Populated by protocol information with established sets/seconds, repetitions, and minutes as established by organization. Use the scroll bar on far right to move through the list to find the desired item you are looking for, all items are listed alphabetically. If the items parameters are exactly like you performed during treatment, tap Set Intervention to save. You must select and set each item individually at the initial evaluation. However on subsequent visits, you will have another option available to Set All Previous which will carry forward the exercises you entered at the prior treatment and make this a quicker process. The most time efficient way to document exercises is via the protocol tab as this should have parameters that your organization has establish ahead of time that are consistent with your practice. On follow up visit if you changed an activity from how you did it the previous visit, select the activity that is most similar to what was performed with the

21 patient then tap Edit Intervention. Each item can be edited to change any of the parameters (sets, reps, or minutes) or to edit the name of an exercise. After editing the item of choice, tap Set Optional to save. This feature allows you to modify an activity to document exactly what was done. Interventions Optional Screen Optional allows access to library of all activities by CPT code, for example (neuromuscular reeducation), (therapeutic exercise), (therapeutic activity), etc. with Interventions listed under each code. Edit Optional is the only option as these items do not have preset set/seconds, repetitions, or minutes. Parameters are only established beforehand when items are in Protocol tab. Interventions Review Screen Review allows you to view items you entered for this patient treatment. Scheduled indicates the number of minutes planned today on PPS Planner, Rendered is the running total on time for treatments administered and Mins +/- indicates how many minutes over or under you are from todays scheduled minutes. If an error is made, you tap on item to highlight then tap Edit Record to change Sets, Reps, or Minutes. If an item was selected in error, tap the item again to remove the highlight. To remove an item completely, select the item then tap Delete Record. When finished >> to advance screens.

22 Treatments Per Protocol Treatments are composed of mainly modalities. Per Protocol lists the most commonly used items. Tap on an item to highlight and Set Treatments if parameters are correct, if not tap Edit Minutes and adjust times as appropriate. Service Based tab lists all CPT codes are that service based, so if an item is not in Per Protocol tab and is service based, it is in this list. Utilize the scroll bar on the far right to access all items on the list. Tap item to highlight and Set Treatments if parameters are correct, tap Edit Minutes and adjust time if different from default. Time Based tab lists all codes that are time based, so if an item is not in Per Protocol tab, and is time based, it will be in this list. Utilize the scroll bar on the far right to access all items on the list. Tap item to highlight and Set

23 Treatments if parameters are correct, tap Edit Minutes and adjust time if different from default. Assessment Screen Post Tx Pain records patients pain rating after treatment. Patient s Response must choose satisfactory or unsatisfactory radio button to enable Set Assessment. Choose Rehab Potential from drop down menu that is appropriate for patient. Tap Set Assessment to save. Assessment Prog Influence Prognosis Influence documents factors that have an impact on outcomes such as level of family support, higher prior level of function, motivation, etc. Tap items to highlight then tap Prog Influence to save. Only one item at a time can be set, repeat process for additional items. Tap >> to advance screen. Review allows you to check data for accuracy of input and to delete items entered in error.

24 Deficits The deficits tab details out items that will be addressed in the treatment via classification and activity. Multiple select as many items as are appropriate for the patient and tap Set Deficits to save. Review tab allows review of data entered and deletion of duplicate activities as needed. Skilled Service Reason Screen Skilled Service Builder is available to further justify the need for skilled intervention. Choose the type of intervention in drop down menu. The statement on the screen will change based on the choice you make from the list. Tap Set Item to save. Choose statements for all issues that are being addressed with patient.

25 In CPT tab you choose the descriptor for the item performed on the left, after choosing an item, the box on the right populates. Choose the appropriate items from the second box that indicate why you are performing the intervention. Review allows you to review all items you have chosen and entered. Items can also be selected and deleted if made in error. Tap >> to advance screen. Goals Goal Builder Screen Tap the Goal Builder banner in the middle of the screen to enter patient goals. Goal Type can be chosen by drop down menu options include Long Term and Short term (mobility, Contractures/Edema/Wound and Pain). Time Frame for goals is chosen in weeks via up and down arrow keys. A goal is built based on components that are chosen that are available in drop down menus including activity, level of assist, and assistive device. The scroll bar on the far right

26 allows all items on the page to be accessed. Tap Build Goal on bottom right corner of screen to put into sentence format for review. Goal will be display on screen and ask if you want to save Yes or No. Once you click yes, you will be returned to the screen and repeat the process for each goal you choose. Once all goals have been established and saved, tap Close to exit Goal Builder. Goal Status is blank at the time of initial evaluation until goals are set. At future visits, goals can be addressed via Goal Status tab.

27 Protocol Goals are goals that have been established by your organization in advance. These do not have to be built as with Goal Builder. Other Goals are additional pre-built goals that are available for use. Multiple select as many as are appropriate then tap Set Goals to save. Review Selections allows you to see items you have chosen and established today and delete. Tap >> to advance screen. Plan of Care Screen

28 Utilize scroll bar to access list of items available in Plan and choose appropriate items by tapping to select. Tap Set Plan Activity to save. Review can be used to review data input and to delete any items as appropriate. Tap >> to advance screen. A pop up may occur indicating minutes are over or under scheduled minutes for this treatment. This is helpful to notify therapists if they are a few minutes shy of meeting goal to facilitate maximum reimbursement. Click Ok to acknowledge. Procedures Summary Screen Payer- displays the patients payer source. Sched min deviation- indicates the difference between minutes scheduled and minutes rendered. Specialty codes-allows tracking of specialty program. Tap line associated with specialty program, choose appropriate program from drop down menu and tap Set Spec Code. The specialty program code will then display in SP code column. Tab Close when finished documenting all items associated with specialty programs. Add treatments-if you get to this screen and realize you have left off an item from your treatment, tap Add treatments. You will return to the Treatments screen and can choose items from Per Protocol, Svc Based, or Time Based lists to complete treatment. After all items have been added, tap Summary in the bottom right corner to return to the Procedure Summary screen. You will receive a pop up screen indicating how many minutes over/under for scheduled

29 minutes your treatment is today. Click ok to acknowledge. If the number of minutes does not match the number of units, you will need to edit units. These calculations are based on the Medicare 8 minute rule. If you have questions regarding this rule and its application to charges, please contact the appropriate person within your organization for clarification. The Charge Grid in the middle of the screen is calculated by adding all of the same CPT codes of activities that you entered during documentation to get a total, and calculating units based on that number. Concur minutes- Allows for the accounting of Concurrent treatment minutes. Select the CPT code of the treatment done concurrently and adjust the minutes to indicate the amount of time the activity was spent in concurrent care. The system will automatically adjust the time spent in non-concurrent treatment as you adjust concurrent minutes and apply it to the PPS plan and billing. Tap Set Concurrent Minutes to save changes. You will see a pop up that summarizes the information you entered. Click ok to acknowledge then Close to leave the screen and return to the Procedures Summary screen. Edit units-allows the editing of units based on professional discretion or to comply with the Medicare 8 minute rule. If you have questions regarding this rule and its application to charges, please contact the appropriate person within your organization for clarification. Choose the item you wish to edit, then adjust treatment time and/or units as appropriate. Tap Set Units to save. You will be returned back to the Procedures Summary Screen.

30 Visit time- Allows documentation of start and end time for patient using the up and down arrows. Tap Set Time to save. You will receive a pop up to confirm, tap ok to acknowledge. Tap Close to exit screen. Schedule- will return you to the main schedule screen. Close visit Allows closing of the note and will return you to the main schedule screen. Patient should be removed from your schedule for that visit.

31 Additional Screens Accessed via Menu or Evaluation Workflows Menu Screen The Menu button will take you to this screen in IPED. The menu screen allows you to quickly navigate to different areas of the note. It is especially helpful early in training and to quickly move to different areas of the note. Tap on the radio button of the area you want to access, in this care Interventions then tap Go.

32 Progress/Recertification Note The progress note/recertification note should be considered another assessment of the patients abilities and the work flow will not change substantially from the evaluation. For greater detail on the functionality of screens, refer back to Evaluation note. Schedule Screen At the schedule screen choose the patient name from the schedule, P indicated visit type of Progress note or recertification. If visit type is not P, change it to P. Tap on the patient name, tap Select Patient for Treatment then >>. The Visit Type drop down menu allows therapist to change the type of note at any time. Any information completed has already been saved and will be carried over to new note type. Tap >> to advance screen.

33 Subjective Chief Complaint (CC) Screen Affected side will have been established at the time of evaluation. Chief complaints can be multiple selected by tapping (highlighted) on appropriate items then tap Set Subjective/CC. To unselect an item, tap on it again and it will remove highlight. Subjective Function Screen Prior Level of Function was established at the time of evaluation and has been saved. It does not have to be re addressed in this note. Tap Current Level of Function Builder and you will be taken to the following screen that allows the therapist to build a statement related to the current level of function status. This can reflect a progression, regression, or plateau.

34 The scroll bar on the far right of the screen is used to access all information on the screen. Once complete, tap Build at far bottom right corner. The current level of function statement is then displayed and you are prompted to tap Yes to save CLF, repeat this process on as many items as are appropriate and then tap Close at bottom left to exit this screen. Tap >> to advance screen. Any other items in the subjective screen such as Pain or Home Assessment can be documented on as deemed appropriate by the therapist. The Comments screen is displayed next to encourage therapists to enter in additional details to paint a clinical picture of the patient and their progress. Please refer to introduction chapter for detailed explanation of adding comments via keyboard or dictation.

35 Using the available gait evaluation screens, you can perform a re-assessment of the patients ambulatory abilities to allow comparison to the time of evaluation. Functional Assessment will first display the previous information entered. Go to Functional tab to enter current level of function and assist. Tap Set Functional to save and >> to advance screen. Utilize Review as needed to check your input.

36 Interventions Screen Previous tab is populated with information detailing last treatment session. Set All copies all activities forward from last treatment to today. Edit allows you to edit the item you have selected by changing sets/seconds, repetitions, minutes, adjusting level or altering the name of activity to document current parameters. Set Intervention allows you to select individual items using current established parameters for current treatment to save. Protocol tab is populated with the most commonly used items for this diagnosis, Options lists all items available by CPT code, and Review allows you to review data input for accuracy or delete a record and to view a running comparison of scheduled to rendered minutes for the day. This is where the Intervention performed with the patient during treatment will be documented. These intervention minutes will add up and then be compared to the scheduled minutes for quick reference in the Review tab. Use the scroll bar to see minutes with each activity and to see the entire list.

37 Skilled Service Reason Screen Skilled Service Builder is available to further justify the need for skilled intervention. Choose the type of intervention in drop down menu. The statement on the screen will change based on the choice you make from the list. Tap Set Item to save. You can also choose items by CPT code. Choose statements for all issues that are being addressed with patient. For additional detail, refer to the evaluation note type. Assessment Screen Post Tx Pain record patients pain rating after treatment. Patient s Response must choose satisfactory or unsatisfactory radio button then tap Set Assessment to save. Updates can be made to any of the tabs available. Tap >> to advance screens.

38 Goals Screen Goal Builder was utilized at the time of evaluation to establish goal. If additional goals are to be added, the therapist would use this tab in the same manner as was done at the time of evaluation. Goal Status allows therapists to update Goal Status by tapping on a goal to highlight, tap Select Goal, then choose from drop down menu in Status to record percentage of goal met. Tap Set Goal Status to save. This process must be repeated for each goal therapist is updating in the note. Tap >> to advance screen. Plan of Care Screen The frequency and duration of treatment can be modified by up and down arrows. Utilize the scroll bar to choose appropriate items then tap Set Plan Activity. If more than one item is chosen in the plan, each must be highlighted individually and tap Set Plan Activity to save each item. Tap >> to advance screen. You may receive a pop up notifying you of the status of minutes rendered compared to minutes scheduled. Click ok to acknowledge.

39 Procedures Summary Screen The top row identifies payer and number of minutes over or under scheduled minutes were performed. The second row allows documentation of the Specialty Codes and the ability to Add Treatments. The treatment section in the middle of the screen tallies all exercise minutes and applies units via Medicare Part B guidelines of the 8 Minute Rule. If you have any questions regarding this rule and its application, contact the appropriate person within your organization for guidance. For Medicare Part A, minutes apply toward the PPS plan. The next to the last row allows documentation of concurrent minutes, allows editing of units based upon therapists professional judgment and closure of the note. The bottom row allows documentation of visit time and the ability to return to the schedule screen. E Signature Screen Check the statement that visit occurred today and enter your password to verify that you completed this note. Tap Save and screen will go back to schedule screen and now the patient will not be on schedule since note is complete.

40 Weekly Note Schedule Screen At the schedule screen choose the patient name from the schedule, W indicates visit type of note is Weekly note. If visit type is not W you can change the visit type. Tap on the patient name, tap Select Patient for Treatment then >>. The Visit Type drop down menu allows therapist to change the type of note at anytime. Choose Weekly from dropdown menu then tap Set new visit type to change. Tap >> to advance screen.

41 Subjective screen allows input related to the affected side, this is established at the initial evaluation. CC- Chief Complaints can be multiple selected by tapping to highlight appropriate items then tap Set Subjective/CC. To unselect an item, simply tap on it again and the highlight will be removed. Document on as many of the tabs as needed to pain the clinical picture. The comments screen facilitates entry of additional detail into the note on each patient to paint the clinical picture. Tap >> to advance screen.

42 A patients gait can be assessed to compare to the findings to the time of the evaluation. Functional Assessment will first display the previous information entered. Go to Functional tab to enter current level of function and assist. Tap Set Functional to save and >> to advance screen. Utilize Review as needed to check your input.

43 Interventions Screen Previous tab is populated with information detailing last treatment session. Set All copies all activities forward from last treatment to today. Edit allows you to edit the item you have selected by changing sets/seconds, repetitions, minutes, adjusting level or altering the name of activity to document current parameters. Set Intervention allows you to select individual items using current established parameters for current treatment to save. Protocol tab is populated with the most commonly used items for this diagnosis, Options lists all items available by CPT code, and Review allows you to review data input for accuracy or delete a record and to view a running comparison of scheduled to rendered minutes for the day. This is where the Intervention performed with the patient during treatment will be documented. These intervention minutes will add up and then be compared to the scheduled minutes for quick reference in the Review tab. Use the scroll bar to see minutes with each activity and to see the entire list.

44 Skilled Service Reason Screen Skilled Service Builder is available to further justify the need for skilled intervention. Choose the type of intervention in drop down menu. The statement on the screen will change based on the choice you make from the list. Tap Set Item to save. You can also choose items by CPT code. Choose statements for all issues that are being addressed with patient. For additional detail, refer to the evaluation note type. Assessment Screen Post Tx Pain record patients pain rating after treatment. Patient s Response must choose satisfactory or unsatisfactory radio button then tap Set Assessment to save. Updates can be made to any of the tabs available. Tap >> to advance screens.

45 Goals Screen Goal Builder was utilized at the time of evaluation to establish goal. If additional goals are to be added, the therapist would use this tab in the same manner as was done at the time of evaluation. Goal Status allows therapists to update Goal Status by tapping on a goal to highlight, tap Select Goal, then choose from drop down menu in Status to record percentage of goal met. Tap Set Goal Status to save. This process must be repeated for each goal therapist is updating in the note. Tap >> to advance screen. Plan of Care Screen The frequency and duration of treatment can be modified by up and down arrows. Utilize the scroll bar to choose appropriate items then tap Set Plan Activity. If more than one item is chosen in the plan, each must be highlighted individually and tap Set Plan Activity to save each item. Tap >> to advance screen. You may receive a pop up notifying you of the status of minutes rendered compared to minutes scheduled. Click ok to acknowledge.

46 Procedures Summary Screen The top row identifies payer and number of minutes over or under scheduled minutes were performed. The second row allows documentation of the Specialty Codes and the ability to Add Treatments. The treatment section in the middle of the screen tallies all exercise minutes and applies units via Medicare Part B guidelines of the 8 Minute Rule. If you have any questions regarding this rule and its application, contact the appropriate person within your organization for guidance. For Medicare Part A, minutes apply toward the PPS plan. The next to the last row allows documentation of concurrent minutes, allows editing of units based upon therapists professional judgment and closure of the note. The bottom row allows documentation of visit time and the ability to return to the schedule screen. E Signature Screen Check the statement that visit occurred today and enter your password to verify that you completed this note. Tap Save and screen will go back to schedule screen and now the patient will not be on schedule since note is complete.

47 Treatment Note At the schedule screen, choose the patient name from the schedule, VT indicates the visit type. T indicates Treatment note. If visit type is not T, you can change the visit type on the next screen. Tap on the patient name, tap Select Patient for Treatment then >>.

48 Visit Type Screen The Visit type drop down menu allows therapist to change the type of note at any time. For Treatment notes visit type is T. If visit type is something other than T, the New Type category is used to change visit type to desired choice. Location should also be appropriate to your discipline or body part depending on your organizations set up choices. If this is not populated or is not appropriate for the patient, use the drop down menu in New Location category to update this to desired option then tap Set New Location to save. This will be the first screen you return to after selecting a patient whose note is incomplete to finish. Tap >> or Menu to advance to next screen. Subjective Chief Complaint (CC) Screen Subjective screen allows input related to the affected side which was established at the initial evaluation and carries over to subsequent visits. CC- Chief Complaints can be multiple selected by tapping to highlight on appropriate items then tap Set Subjective/CC to save. To unselect an item, simply tap on it again and the highlight will be removed. Tap >> to advance screen. If pain rating is taken, this can be documented in the Pain tab. All information in tabs is available for documentation but not required. The level of detail in documentation is relative to the patient, therapist, and organization. MedAdept refers you to your organization for clarification on their specific requirements.

49 Previous tab contains the details from the previous treatment. Tap Set All Previous to copy forward all details from previous treatment. If parameters of the activity were changed for today s treatment, tap the activity to highlight, then tap Edit. The name of the exercise can be edited by tapping the box, sets/sec, reps, and minutes can be edited by up and down arrows to reflect changes and Level can be used to add more detail, for example use of green theraband, dumbbell weight, etc. Tap Set Intervention to save. New or additional interventions performed with patient can be entered via Protocol or Optional tab. In Protocol, items are entered by tapping to highlight and select. If parameters are correct, tap Set Intervention. If parameters need adjusting, tap Edit Intervention to adjust parameters and then save. Protocol tab has all preset parameters that were established by your organization with MedAdept. Optional contains the entire library of exercises based on CPT code. The CPT Code is chosen and then populated the interventions. Tap on an item to highlight, then tap Edit Optional.

50 The next screen will allow for the editing of all parameters related to the activity such as edit exercise name, change CPT code if needed, sets, reps, and minutes must be manually entered with up and down arrows and position is needed. Tap Set Optional to save. Review is used to review information for accuracy and delete any items if needed. This process is repeated until all interventions from today s treatment are recorded. Tap >> to advance screen. Review tab allows therapist to check the accuracy of information input for today s treatment as well as keep a running tally on minutes rendered (tally is

51 based on minutes applied to rendered interventions and are grouped together by CPT code). By scrolling over you will see the number of sets, reps, and minutes of each activity. The top line identifies the number of Scheduled minutes for Medicare Part A, Rendered minutes are tallied by the number of minutes rendered in today s treatment and Minutes +/- compares scheduled minutes to rendered minutes to indicate the number of minutes over (+), under (-), or equal (0) you are for the day. This is helpful to quickly see if you met the minutes required to achieve a given RUG level and avoid missing out on reimbursement. Review tab is where activities can be reviewed for accuracy or deleted. Tap >> to advance screens. Assessment Screen Post Tx Pain records patients pain rating after treatment. Patient s Response must choose satisfactory or unsatisfactory radio button to enable Set Assessment. Comments can be utilized to enter greater detail as appropriate. Tap Set Assessment to save and >> to advance screens.

52 Tap to highlight items in plan then tap Set Plan Activity. Plan component allows therapist to input plans for next treatments, for example increasing level or exercises, increasing resistance, etc. Comments section allows ability to document any additional detail. Tap >> to advance screen. Procedures summary screen displays a summary of information entered by therapist for the treatment. Documentation can be performed here for Specialty Codes and Concurrent Minutes. Treatments can be edited, or added. Visit Time is documented here. Once all information is complete tap Close Visit. Therapist is prompted to check statement verifying visit occurred today, input password and tap Save. You will then be returned to schedule screen and patient name will be removed from schedule since note has been completed.

53 **If all patients that are scheduled on a given day are treated, at the end of the day the therapists schedule will be empty. Discharge Note Schedule Screen At the schedule screen choose the patient name from the schedule D indicates visit type of note is Discharge note. If visit type is not D you can change the visit type. Tap on the patient name, tap Select Patient for Treatment then >>. The Visit Type drop down menu allows therapist to change the type of note at any time. Choose Weekly from dropdown menu then tap >> to advance screen.

54 Subjective screen allows input related to the affected side, this is established at the initial evaluation. CC- Chief Complaints can be multiple selected by tapping to highlight on appropriate items then tap Set Subjective/CC. To unselect an item, simply tap on it again and the highlight will be removed. You can document on any tabs available in the screen that are appropriate. Comments screen allows documentation of information to paint a clinical picture of the patient. Gait Assessment Evaluation Screen Drop down menus are available to document surface, level of assistance, assistive device, distance ambulated and minutes. These minutes do not count toward PPS minutes as they are evaluative in nature. Once parameters are set

55 tap Set Gait to save. To access remaining tabs at bottom of screen simply tap on desired screen to show information. Additional information may be added to other tabs as appropriate. Functional Assessment Previous Level Screen Previous Level of function indicates what patient has done in the past for functional activities with transfers broken down into various components. In discharge notes, items may be updated by tapping to highlight chosen item then tap Select Item. Then enter current Score via drop down menu then tap Set Level. Documentation of current level can also be documented in Functional tab. Interventions Intervention is populated with information detailing last treatment session. Set Previous copies all activities forward from last treatment to today. Edit allows you to edit the item you have selected by changing sets/seconds, repetitions, minutes, adjusting level or altering the name of activity to document current parameters. Set Intervention allows you to select individual items using current established parameters for current treatment to save. Additional interventions may be added via Protocol or Optional tabs as well. Utilize review to check for accuracy or to delete items. Tap >> to advance screen.

56 Skilled Service Reason Screen Skilled Service Builder is available to further justify the need for skilled intervention. Choose the type of intervention in drop down menu. The statement on the screen will change based on the choice you make from the list. Tap Set Item to save. Choose statements for all issues that are being addressed with patient. You can also use CPT tab to build in justification. Tap >> to advance screens. Assessment Screen Post Tx Pain records patients pain rating after treatment. Patient s Response must choose satisfactory or unsatisfactory radio button to enable Set Assessment. Address any other tabs available as needed.

57 Goals Goal Builder Screen Tap Goal Status tab to update patients progress toward goals. Tab to highlight goals and update status via drop down menu. Tap Set Goal Status to update and save. Tap >> to advance screens. Plan of Care Screen Utilize scroll bar to choose appropriate items, on discharge you are explaining reason for discharge or discontinuation of services. Choose items as appropriate then tap Set Plan Activity. Tap >> to advance screens.

58 Procedures Summary Screen ADD in DESCRIPTION E Signature Screen Check the statement that visit occurred today and enter your password to verify that you completed this. Tap Save and screen will go back to schedule screen and now that patient will not be on schedule since note is complete.

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