SOAP notes Archives | WebPT

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Physical Therapist Assistant vs. Physical Therapy Tech: What’s the Difference?

You don’t necessarily have to be a doctor of physical therapy (DPT) to work in the physical therapy industry . In fact, you can make a huge difference in your patients’ lives by serving in a supporting role—especially as a therapist assistant or therapy technician. Now, these jobs might sound like a “poh-tay-toe,” “poh-tah-toe” kind of situation. And by that, I mean: same job, different name. Right? Well, don’t let their names fool you; the roles are …

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Is Your Physical Therapy Software Ready for ICD-10?

At this point, the majority of physical therapy clinics are using some type of software to document, schedule, and bill for patient treatment. Thanks to ever-increasing compliance regulations, paper had to go the way of the VHS, becoming nearly obsolete. When your practice switched from paper to software, it was a big change.

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How to Complete Functional Limitation Reporting in WebPT

As of July 1, 2013, the Centers for Medicare and Medicaid Services (CMS) requires that therapists complete functional limitation reporting (FLR)—through the use of G-codes and severity modifiers—on all eligible Medicare Part B patients at the initial evaluation, re-evaluation if applicable, every progress note (minimum of every ten visits), and discharge in order to receive reimbursement for their services. Today, several other private insurance companies also require FLR data as a condition of reimbursement. Good thing WebPT has you covered. Read on to learn how Members can use our totally free, built-in, easy-to-use functional limitation reporting feature.

Initial Evaluation

Subjective Tab
Prior Level of Function

In the Subjective Tab, you’ll find a section labeled Prior Level of Function. There, you will select your patient’s prior level of function—the areas in which the patient was independently functioning prior to seeking treatment. This information provides supporting evidence and context for your patient’s history. (Note that this section is Medicare required. If you miss this step for a Medicare patient, an alert will prevent you from finalizing your note.)

Prior Level of Function screenshot
Current Functional Limitation

Next, you’ll see the Current Functional Limitation section. There, you’ll select your patient’s current functional limitation(s) (check all that apply). This information will also provide supporting evidence and context for your patient. (Note that this section is also Medicare required. If you miss this step for a Medicare patient, an alert will prevent you from finalizing your note.)

current functional limitation
Primary Functional Limitation

From there, we’ll prompt you to select your patient’s primary functional limitation category (self care; changing and maintaining body position; mobility: walking and moving around; carrying, moving, and handling objects; or other). Based on this information and the visit type, we’ll autocomplete your G-codes.

primary functional limitation
Objective Tab
Objective Measurement Tools

To identify your patient’s current functional severity and track his or her progress towards the goal, you’ll use the results of an outcome measurement tool (OMT) and your clinical judgement. In this section of the Objective Tab, you’ll be able to select, perform, and score your OMT—and we’ll help you decide which tools to use. There will be a badge next to the outcome measurement tools we feel are most appropriate to use considering your patient’s primary functional limitation (e.g., “M” for mobility: walking and moving around). You can go with our suggestion or choose your own.

OMT
Functional Reporting

Under Status Modifier, you can select the appropriate severity modifier for your patient’s current status (how severe the patient’s limitation is at this moment in time) and projected long-term goal status (how severe you believe the patient’s limitation will be at the end of treatment). This is the first of two opportunities you’ll have to actually apply severity modifiers. If you choose to skip this step here, you must complete it in the Assessment Tab.

functional reporting
Assessment Tab
Severity Modifiers

Beneath the Assessment/Diagnosis field, you will have a final opportunity to choose your severity modifiers. Here, you can also document the clinical rationale you used to make your selection. This text box will automatically populate based on the outcome measurement tools you selected. (If you already made your severity modifier selections in the Objective Tab but now wish to change them, you may do so using the dropdown menus in this section. Your new selections will replace those in the Objective Tab.)

severity modifiers
Problem List and Goals

WebPT will automatically transfer your patient’s primary functional limitation and corresponding goals into the Problem List and Goals test boxes. We will also adjust your goal met percentages in accordance with your patient’s progress. However, you will still need to manually select a goal duration using the dropdown menus.

problem list

Daily Note

Your finalized daily note will automatically display your patient’s primary functional limitation, current status, projected goal status, rehab potential, and long-term goal.

daily note

Progress Note

On your next progress note (at minimum on your patient’s tenth visit), the system will prompt you to complete functional reporting again. Here, you’ll perform an OMT and—using the results and your clinical judgment—update your patient’s status and severity modifiers as well as verify his or her long-term goal. Just like on the initial evaluation, this information will automatically appear in the problem list and goals boxes.

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Discover Ideas in Action–November 2011

Upon logging in this morning, thousands of WebPT members across the country accessed a newly improved system. We’re grateful to all of the members who helped make these improvements possible. Over 30 members submitted ideas that were implemented in the release that happened late Friday night! Many members even saw more than one of their ideas come to life.
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