WEdoc: Therapy Documentation System Basics

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1 WEdoc: Therapy Documentation System Basics Complete Insurance Verification Request Form (Form may be found on TWG Website) Select Employees Select Payroll Website Enter username and password Select TWG Forms Select Operations Select Insurance Verification whh Form PDF ( ) It is recommended that you Type information into this form, completing in its entirety. 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. Select Patient (all patients associated with therapist via insurance verification process will appear)

2 Search for patient by typing last name in search field. Select patient by clicking magnifying glass. This opens the patient chart. To Complete Initial Evaluation Evaluation date and Additional Tests and Measures Dates must match in order to populate the 700. Onset date may be different as it is the date of the precipitating event that brought the patient to the physician s notice, resulting in the referral for therapy. Click Edit Patient Admission Details (Therapy Onset Date, located in the Diagnostic Codes tab, is the date of precipitating event that brought the patient to the physician s notice, resulting in the referral for therapy. This date populates the 700 as Onset Date the initial evaluation date populates the 700 as SOC Date ) The Diagnostic Codes tab is where you edit medical dx codes, add your rehab dx codes, enter previous hospitalization dates. Click Additional Tests & Measures (These are the valid / reliable standardized assessments also used to calculate G-Code Severity Modifiers) Select from drop down lists; To populate the 700 correctly, PTs must select Functional Mobility and Gait Balance Posture; OTs must select Functional Mobility and ADLs; Add any other standardized tests needed. Do not use Berg Balance Assessment at this time; Add new tests and measures. Click Initial Evaluation (For medical records security, you will have 30 minutes to get through the following 6 Tabs. If not completed in that time frame, you will be logged out of Wedoc. Remember, this is protected patient healthcare information) Do not SAVE until completing all 6 tabs. 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 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

3 Back to patient chart Click Rehab Visits (these are your charges for the treatments provided and where you enter G-Codes) Type of service (CPT codes such as 97112); enter minutes; Add visit. Click CBOR Calculator at top of page to obtain G-Code severity modifier based upon results of functional assessment. Type of Service; Select G-Codes (Current and Goal); enter 0 minutes; enter severity modifiers (CK); Add visit. Click Progress Note (write daily SOAP note) or narrative Add new note; complete current assessment tab; complete narrative tab, include documentation regarding G-Code and severity modifier. To print 700 to fax to physician: Click on Initial Treatment Plan Sign and fax to physician office For Routine Visits -Click on Rehab Visits (enter your charges) -Click on Progress Note and write a daily narrative For 10 th Treatment Visit Supervisory Progress Report -Click on Rehab Visits (enter your charges and update G-Codes (Current and Goal) and severity modifiers -Click on Progress Note, complete assessment tab, Title the narrative Supervisory Progress Report write a progress report narrative, and address goal status. (Click on calendar to select date, enter current status) include documentation regarding G-Code and severity modifier. For Supervisory Notes when Assistants have been providing Care (Per State Practice Act) May combine with the 10 th Visit Supervisory Progress Report Above on or before 10 th visit -Click on Rehab Visits (enter your charges) -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) 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 (Be succinct, 2-3 lines of text)

4 Save 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 Click Rehab Visits (these are your charges for the treatments provided) Type of service (CPT codes such as 97112); enter minutes; Add visit. (Update G-Codes and severity modifiers) Click Progress Note (write daily SOAP note) or narrative Add new note; complete current assessment tab; Title Narrative Recertification Report complete narrative tab. Include documentation regarding G-Code and severity modifier. To print completed 700 for Therapist s Signature: Click on Initial Treatment Plan Sign and place in patient s manila folder in locked file cabinet To print 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 and fax to physician office 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, including G-Code and severity modifier details. Click Goals Tab Enter current (end) status Save -Click Treatment Plan Click Last tab on top Outcomes; Barriers to Function enter Discharge Summary Here 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 Click Rehab Visits (these are your charges for the treatments provided) Type of service (CPT codes such as 97112); enter minutes; Add visit. Click CBOR Calculator at top of page to obtain severity modifier based upon results of functional assessment. Type of Service; Select G-Codes (Goal and Discharge); enter 0 minutes; enter severity modifier; Add visit. To print Discharged 700 or 701 for Therapist s Signature: Click on Initial Treatment Plan (or Updated in case of 701) Sign and place in patient s manila folder in locked file cabinet Upon Completion of Documentation: Sign Out When you see message You have successfully signed out select OK Select Close button (located beneath the Wedoc logo) Exit all windows completely, to the desktop

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