WEdoc: Therapy Documentation System Basics

Transcription

1 WEdoc: Therapy Documentation System Basics Complete Insurance Verification Request Form (Form may be found on Website) Select Employees Select Payroll Website Enter username and password Select Forms Select Operations Select Insurance Verification whh Form PDF ( ) Type information into this form, completing in its entirety for Part B patients. Complete only top 2 sections for Home Health patients. Return completed form to corporate billing using your assigned billing e-fax number or using internal to efax. Once billing has received, the insurance verification will be completed in hours. The patient will be sent to EMR entry specialist for entry into WEdoc. To access WEdoc therapy documentation system: Go to website Select Employees Select Payroll Website Select WEdoc Therapy Documentation System Enter Username: First Initial of first name, full last name Example: FLast (Note: User name is NOT case sensitive) Enter Password: First Initial + Last Initial + Last 4 Digits of SSN Select Patients Example: FL1234 (Note: Password is ALWAYS case sensitive) Click Activities for Physical Therapy Caseload, Occupational Therapy Caseload, Speech Therapy Caseload depending upon your discipline.

2 Select Patient (all patients associated with therapist via insurance verification process will appear) You may search for patient by typing last name in search field (or type only first 4-5 letters of last name). Then click on magnifying glass under search box to begin search. Select patient from list of names that appears by clicking magnifying glass (on right side of screen by patient s name). This opens the patient chart. To Complete Initial Evaluation Make certain dates match for all info contained in evaluation including onset, SOC, additional test and measures dates Click Edit Patient Admission Details This is where you edit medical dx codes, add your rehab dx codes, enter previous hospitalization dates, and any other demographic or physician info necessary. Ensure that for any DX showing one or two asterisks (* or **), that you enter the 4 th or 5 th digit for the diagnosis selected. Click Additional Tests & Measures Select from drop down lists: Functional Mobility; (to document bed mobility and transfer status) Gait Balance Posture; (to document gait pattern, postural stability and dysfunction) Tinetti POMA Gait and Balance Assessment; Hip (or any other region) for Strength, ROM, Etc.; Do not use Berg Balance Assessment at this time; ADD new tests and measures. Click Initial Evaluation Complete Initial Assessment Tab Complete Summary / Rationale Tab (Enter no more than 3 lines of text) Complete Goals Tab (be succinct. limit characters, text to 2 lines in rectangular field) Select goal type (ST or LT); start date; projected date; start status; then add goal. Complete Plan Tab Check appropriate boxes; enter frequency and duration

3 Complete Evaluation Visit Tab (your charges for the eval) Date; PT Eval; 30 minutes Complete Certification Tab Enter cert period dates, check treatment plan ready to be certified ; SAVE. Back to patient chart Click Progress Note (write daily SOAP note) or narrative Add new note; complete current assessment tab; complete narrative tab. To print 700 to fax to physician: Click on Initial Treatment Plan This will open your 700 as a.pdf Print the 700 from here (select printer icon) Sign and fax to physician office For Routine Visits -Click on Progress Note, complete assessment tab, and write a daily narrative For 10 th Treatment Visit Progress Report -Click on Progress Note, complete assessment tab, Title the narrative 10th Visit Progress Report write a progress report narrative, and address goal status. (Click on calendar to select date, enter current status) For Supervisory Notes when Assistants have been providing Care (Per State Practice Act) -Click on Progress Note; complete assessment tab, Title the narrative PTA Supervisory Visit write a narrative, document "PTA supervisory visit complete. PTA following POC, patient and family pleased with care provided"; address goal status. (Click on calendar to select date, enter current status) For Recertifications Click Patients Click Activities for PT Caseload Select Patient Click Treatment Plans Click pencil icon; Outcomes Tab; Barriers to Function and enter narrative; Prognosis and enter; enter service dates; check box Yes to continue this will close original 700 and open 701. Certification tab: check Plan has ended (you may not enter new plan until previous plan has ended)

4 Back to Treatment Plans Add new plan Enter date, check box plan ready to be certified Click Current Assessment Tab and complete Click Reasons for Continuation Tab and complete Click Goals Tab Update goals as having been met or continue by entering current status; you may add additional goals here. Click Plan Tab Check appropriate boxes and enter frequency and duration Save Click Progress Note (write daily SOAP note) or narrative Add new note; complete current assessment tab; Title Narrative Recertification Report complete narrative tab. To print completed 700 for Therapist s Signature: Click on Initial Treatment Plan This will open your 700 as a.pdf Print the 700 from here (select printer icon) Sign at bottom of page and place in patient s manila folder in locked file cabinet To print new 701 to fax to physician: Click on Updated Treatment Plan This will open your 701 as a.pdf Print the 701 from here (select printer icon) Sign at middle of page and fax to physician office for signature For Discharges -Go to patient chart Click Progress Notes Add new note Click Current Assessment Tab Enter Date; D/C date; PT D/C Reason Click Narrative Tab Enter Discharge Summary narrative Click Goals Tab Enter current (end) status and Save -Click Treatment Plan Click Last tab on top Outcomes; Barriers to Function enter Discharge Summary Here, including any remaining limitations. Remember to document in this summary that you have notified the physician of discharge. Prognosis enter statement that patient has been discharged from TWG Services Enter Service From and To Dates Continue Service: Check No Click First tab on top Certification ; check box Plan has ended

5 To print Discharged 700 or 701 for Therapist s Signature: Click on Initial Treatment Plan (or Updated in case of 701) This will open your 700 or 701 as a.pdf Print the 700 or 701 from here (select printer icon) Sign at bottom of page and place in patient s manila folder in locked file cabinet