Checklist: Initial Evaluation

Want to know if you got it all done? Here's a quick checklist!

Schedule:

• Schedule appointment with patient and add to your EMR calendar so team members are aware of the appointment;

• Choose the correct visit type:

  • Initial Evaluation

  • Initial Evaluation with Intake

  • Initial Evaluation Out of Area (for a negotiate out of area rate)

For the Initial Visit, Bring With You:

• PPE including gloves and masks

• Blood pressure cuff

• Any additional testing equipment or tools you need

... And Leave With...

• A scheduled appointment for your next visit with the patient.

Documentation for the Initial Evaluation

For your first therapy visit with a patient, once the visit is "Scheduled" and "Arrived" you will have a blank chart screen.

1. Load the Evaluation Frame Template for your Discipline (PT/OT)

2. Choose your Objective (second template) for 4. PT OT Evaluation Objective Templates.

3. 
   

Mandatory Fields

Once the template is loaded, there are fields that are marked as mandatory (based on regulatory guidelines). Here is an explanation as to the content we are looking for:

Onset Date: This is the date that the condition first started or the date in which decline was first noted. This is typically NOT the date of the MD referral. If an exact date is not known, you can use the first of the month. For example, assuming today is 1/1/2022, "Patient presents for ST Evaluation with a history of PD x 5 years. He received prior ST therapy in 2018 with good results. Today, patient's spouse reported that shortly after Thanksgiving, she noticed that her husband was coughing more during mealtime and there was one episode of choking last week during dinner. Medical care was sought and ST evaluation ordered". For this scenario, the date of onset would be 12/1/2021.

Referring Dx: The diagnosis provided by the referring medical provider such as "PD", "Dementia", etc.

Treatment Diagnosis: The conditions you are treating as a result of the primary/medical dx. Examples include muscle weakness, history of falling, limitation of activity due to disability, etc. A list of the most commonly used codes is included.

Rehab Therapy Within the Past Year: If patient received therapy within the past year at any location (i.e., hospital, home health, outpatient) please note what was received and patient perceived outcome of the intervention.

Detailed Narrative: The emphasis is on the "detail". The history should be sufficient to explain why skilled therapy services are needed. It is NOT sufficient to only document "patient well known to this therapist through prior intervention" unless you plan on attaching all medical records to provide history.

Patient/Family Goal for Therapy: Let's not forget why we are here. I suggest always making the patient/family goal one of your treatment goals!

Total # of Visits to Achieve POC: As an outpatient therapy provider, we have some flexibility in visit frequency and duration and use total POC visits as a reference and then recommended frequency/duration.

Creating Goals:

When charting a patient visit, Insight allows you to mark any line item as a goal for tracking. Most items include a default goal value (such as Independent in HEP) but you can adjust the end status/desired goal outcome manually within the chart using the Goal Worksheet. See InsightGO "?" for how to do this or watch the desktop video here:

Documenting Procedures

The Template includes the most common procedure codes used. Please be sure to justify your time by entering minutes for each procedure code used. If a procedure is not relevant, you can put "zero" for minutes or leave blank. An initial evaluation can not be billed for less than 15 minutes.

Adding Content to Case Editor

The system is not able to "read" chart notes so some information needs to be entered in the Case Information / Client Editor tab for billing and tracking. Information that needs to be added includes:

Onset Date: From Your Evaluation

Signature Date:The date the intake paperwork was signed (if done by you)

Admit Date = The date of the evaluation

ICD-10 Diagnosis: Primary/Medical and Treatment Diagnoses

Add Plan of Care and Add Progress Report

This sets the tracking for the certification period and number of visits until the next progress report is due.

Sign Off

You will be able to review procedures billed and time spent prior to sign off. Once you electronically sign the note, the visit documentation is "locked" and cannot be changed by anyone except for you.

Learn More:

Watch the video here

PLEASE DO NOT FAX THE REPORT DURING SIGN OFF

LIFECARE WILL REVIEW AND FAX FROM OFFICE WITHIN 1-3 DAYS OF YOU SIGNING THE REPORT

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