Patient Identity Confirmed: Must be checked on EVERY document submitted, even if the patient is already known to you.

 Times: Times present MUST be in military format (e.g. "1:00 PM" is "13:00"). Must be inputted to save document.

 Date: This is the date of the visit, and MUST match the date in your HotBox. Must be inputted to save document. If you get an error while saving, contact the office prior to completing the rest of the document.

 Mileage: Can be left blank.

 HCPCS: These are automatically generated--make sure that the location dropdown on the right matches the location the patient is treated. This is needed for billing.

 Medical Diagnosis: The medical reason the patient was admitted to services. The date of onset is the onset of the condition (e.g. date of initial hospitalization) or "Exacerbation" may be selected and can be the date of admission to the agency, hospital admission, etc.

 PT Diagnosis: This is YOUR reasoning for seeing the patient. May be as simple as "Generalized Weakness" or "Difficulty in Walking". Date of onset should be your evaluation date.

 Relevant Medical History: This is your PMH section--just list out the patient's diagnoses that are applicable to your care.

 Prior Level of Functioning: This should just be a simple statement. If patient previously had deficits, such as walking with a cane or assistance was needed with ADLs, you can put that here as well

 Patient's Goals: This is what the PATIENT wants to get back to doing. Using a quote from the patient simplifies this, but isn't necessary.

 Precautions: Fall risk is the number 1 reason we're seeing a patient most of the time, so it should be on most of your documents. Also include hip precautions, sternal precautions, etc. as applicable.

 Homebound: Always answer "Yes" to this. "Requires max assistance / taxing effort to leave home" should ALWAYS be checked, along with at least one other checkbox. The "Other" section might include information, say if a patient has a psych diagnosis that impairs leaving home

 Current Types of Assistance Received: In this box, just put who is assisting and their availability. Family, friends, paid caregivers would all be listed here. If they live in a PCH/ALF, then you can put "Staff at PCH" or whatever seems appropriate.

 Safety / Sanitation Hazards: Check all that apply. Steps / Stairs is non-specific, so input what makes the most sense to you based on your assessment.

 Evaluation of Livin Situation, Supports, and Hazards: This section is regarding the specific setup of the patient's home environment. Stairs and bedroom/bathroom locations are important to note as well as any other potential areas that could have an effect on treatment (e.g. a gravel driveway will mean that instruction in ambulation on uneven surfaces is relevant to the patient).

 Temperature: Should be taken when a potential for infection is present (e.g. open wounds, suspected UTI or other possible infection).

 Blood Pressure: Needs to be taken prior to treatment, ensuring that the "Position" and "Side" drop-downs are also selected.

 Heart Rate: Needs to be taken prior to treatment.

 Respirations: Needs to be assessed prior to treatment.

 O2 Saturation: Can be taken as per clinical judgement. Orders for this are no longer needed. Be sure to select the "Room Air / Rate" and "Route" drop-downs to the right.

 Comments: **IMPORTANT: If any of the vital signs are outside of agency parameters, they must be addressed and the communication should go here (e.g. SN made aware, PCP called regarding HTN, etc).

 Subjective Information: Quick assessment of patient's overall current status.

 Systems Assessment: Select one of the responses in each drop-down and note any anomalies in the corresponding text box.

 Edema: Must select "Absent" or "Present" and input the location. Other areas are not necessary for the majority of patients.

 Psychiatric Worksheet: This link is just stuck in there and is easily missed. If there's a psych diagnosis that may affect treatment, this can be filled out but is not necessary.

 Pain Assessment: Must be completed every visit (select "No Pain Reported" if there's no pain). Fill out all the corresponding boxes.

 Wound Care Worksheet: Like the psych assessment, this is stuck randomly in between items. This is only necessary to fill out if there are current wounds being addressed by the agency and your discipline is assessing them.



 ROM / Strength: This needs to be filled out for the body parts that will be worked on--for PT, usually lower extremity. WNL or WFL is acceptable for ROM. OT is much more limited with just the upper extremity section.

 Available: Check off all that apply. In the "Other" section add whatever else they have. The OT section has slightly different selections.

 Needs: Input any devices that are needed for safety. For these, make sure to note where these are coming from (e.g. PT to order, DME company is delivering this week, patient's sister is providing).

 Patient information: Age, gender and the doctor ordering therapy.

 Reason for Admission: Medical diagnosis resulting in hospitalization or for ordering home health services and dates.

 Admission Information: Include hospital and dates (if applicable); inpatient rehab and dates (if applicable).

 Relevant Information: Include details such as presence of pain, edema, stiffness, ROM issues, mobility difficulties since arriving home, etc.

 Therapy Assessment: Include deficits found in assessment. Specifics such as numbers found during testing are NOT needed, but the outcome is; what does fall risk score indicate; what deficits in mobility do these cause?

 PLOF: Where was patient at prior to admission to hospital / visit with physician and, if different, what are the basic goals (e.g. "Patient was previously independent with ambulation, but will likely be mod I with RW due to ongoing deficits from CVA.").

 Therapy Plan: Will patient benefit from therapy? What deficits will be addressed? Include the statement "to return to PLOF" or "maximize functional mobility" or similar to indicate why this treatment is medically necessary.

 Patient involvement in POC: Blanket statement indicating that the patient was involved in the POC and goal formation and that they're agreeable to the finalized treatment plan.

 **Insurance companies tend to ONLY look at narratives when quickly reviewing notes; narratives also provide the office staff with a quick look to get authorization so make sure all pertinent information is present!

 When filling out this section, the "Interventions" are what was previously called the "Orders" prior to changes from CMS.

 Select the blue "Update Goals and Interventions" button to add



 A page will open and your current evaluation will be saved. Click the blue "New Goal" button to add a goal.



 A page will pop-up over the original to allow you to select goals. In the example, "shs" has been typed into the search bar to bring up relevant goals that are sanctioned by the agency. You'll be able to do this by discipline ("phys" for PT; "occ" for OT; "speech" for ST). These are suggested goals, and are by far not all inclusive. You can search for other goals or enter free text by clicking the button in the bottom right corner.



 This image shows that you can select multiple goals at once by clicking each. Clicking a second time will remove the goal. By clicking "Continue" all highlighted goals will be added.



 If you have selected a "Free Text" goal, this screen will be shown. Under the "Instructions" section, type in your goal and select "Assign". You will have to manually add interventions.



 The fall risk goal is shown as an example. Any white box is required to be filled in. At the top, the date section must be filled in along with the term of the goal. Selecting "by the end of the episode" will fill the date box in with the last date of the certification period. In this example, you would fill in the standardized test, the initial measurement and the goal measurement. Suggested interventions are present below the goal. Clicking the "X" on the right of the intervention will remove it from the list. Once completed, click the blue "Assign" button.



 Once assigned, the goal will appear as in the picture (screen shot is not for the same goal). The green "Perform" button will allow you to select which intervention is performed during the visit.



 Once the "Perform" button is selected, this screen will come up. You must select who the intervention was performed on and the result of the instruction. Notes should be left blank.



 After all the interventions are performed (as applicable--a minumum of one intervention must be performed to demonstrate working on the specific goal), you will return to the goal. Clicking the "Document Progress" button on the upper right side will allow you to select patient progress toward the goal. In the "Goal Progress Notes" section that pops up, here is where you can provide more information on the interventions performed. Click "Submit" on the bottom right to save.



 Now that the goal has been addressed, this screen will come up. Note that the "Goal Progress Notes" section appears here above the interventions. Each visit more notes are added here, allowing you to visualize the patient's progress. After all goals are addressed to your satisfaction, click the blue "Return" button on the bottom right.



 You are now returned to your evaluation page. Whereas the "Treatment Goals and Plan" section was previously blank, you will now see the goals added and interventions performed.

 Care Coordination: The checkbox for "Physician Notified RE: Plan of Care..." MUST be checked on all evaluations (even eval-only). The communication part should include anyone that you've involved during your visit.

 Statement of Rehab Potential: For any evaluation where further visits are planned, "Yes" should be checked; for evaluation-only "No" should be checked.

 Treatment / Skilled Intervention This Visit: The checkbox for "Completion of the evaluation..." MUST be checked on all evaluations (even eval-only). The "Other" section is actually regarding other skill provided, which is already present from the "Goals and Interventions" if any interventions were performed. This can be completed as needed, or leave unchecked.

 Frequency and Duration: The current episode's start and end dates autofill. The effective date is the date of the evaluation. Frequencies should be listed out in the "# w #" format. The "Next Episode" section will only be used if the evaluation is performed in the last 5 days of the certification.

 Checkboxes: Select all that apply. Other is frequently used in place of these (e.g. "To staff at PCH when goals met / max potential reached" or "To care of family when goals met").

 Templates: You can elect to save the evaluation as a template for future use. For instance, if you see a lot of knee replacements you could entitle this "TKR" and have it available and just modify it as needed the next time you have a new knee replacement patient.