General Documentation Training

This guide contains on overview of the documentation module and documentation workflow. For more specific looks into areas of the Documentation module, see the TheraOffice: Documentation section of this help guide. In addition to the Documentation module in the software, we also have a Documentation app available for the iPad.

TheraOffice Onsite and Web, version .9 or above

Patient Navigator

The image above shows the Patient Navigator in the Documentation tab.

TheraOffice Documentation is patient specific, so much of the time you spend documenting for patients will be within that patient's navigator. In the patient navigator, be sure to navigate to the Documentation tab at the bottom of your screen. The patient's chart appears at the center of the screen, with vitals to the left and graphs illustrating the patient's progress to the right.

Cases

The image above shows a Patient Case with the Main tab selected.

Cases are used to group together information for the course of a patient's care. You can separate a single patient's notes for different injuries/diagnoses, different insurances, or even separate prescriptions.

You can have multiple cases open within one patient simultaneously, and-when finished with a case-you can discharge the patient within that case without discharging all others.

The Difference Between Reports and Data

The image above shows where to identify a document's type from the clinic navigator.

Within the patient's chart, you will find a few different types of documents: most notably, data and reports. While these contain essentially the same information, they do have a few fundamental differences.

Data is used to actually document on the patient. Here, you will find the Document Editor, where you fill out the note. We will discuss filling out these notes in the Data section of this chapter. Data can only be accessed by providers, regardless of security permissions.

The image above shows the Locked Documents view in a patient's chart.

Document Reports take the information from the data and distill them into printable, easy to read reports. Reports can be used to generate readable versions of the notes to fax to physicians or provide to the patient, or they can be used to create specialty reports that serve specific purposes, such as plans of care or home exercise programs. Document reports can be accessed by any user with the correct security permissions, regardless of their license types. To see a list of all a patient's document reports, click into the Locked Documents view.

Document Organizers and Unlocked Documents

The above image shows where to access Document Organizers and Unlocked Documents from the Home Tab or Clinic Navigator.

As a provider, you can manage your documentation to-do list for all patients using Document Organizers and Unlocked Documents.

Document organizers are automatically created when a patient is checked in from Scheduling. They serve as bookmarks to indicate to the provider which patient was seen at a particular time, and the note type to be filled out based on the type of appointment the patient was seen for. After you use the document organizer to start the note for the patient, the organizer goes away.

Once a document is started for a patient, that document is considered an Unlocked Document until the data is completed and locked.

A provider specific list of Document Organizers and Unlocked Documents can be accessed by dropping down the Documentation menu on your home screen or from the top ribbon toolbar.

This image, above, shows the Pending Documents widget unexpanded on the clinic navigator.

You may also find the Pending Documents widget to be helpful, as this widget places your Document Organizers and Unlocked Documents in one place, together.

Types of Notes

Flex Notes: Essentially blank word documents used to collect miscellaneous data not related to a specific appointment. Flex Notes are not technically considered data, so they do not generate reports and can be accessed and created by all users with permissions, not just providers.

Image Notes: Allow you to scan in case specific information and images, such as prescriptions or x-rays. Image Notes are not technically considered data, so they do not generate reports and can be accessed and created by all users with permissions, not just providers.

Initial Evaluation: This note type includes fields typically used when evaluating a patient, including MIPS and goals.

Daily Note: Daily Notes are most commonly used for documenting a patient's return visits, includes the option for billing.

Progress Note/Daily Note: Used for generating a progress note with billing attached.

Progress note: Used for generating a progress note without billing. These are typically used when the patient is not in the office. (Ex: If the physician calls and asks for one) Note that progress notes do not include billing.

Discharge note/Daily: Most commonly used for documenting a patient's final visit for the case to discharge them from care. This note includes billing.

Discharge note: Typically used to discharge a patient from care if they simply stop scheduling appointments (aka, self-discharge.) Note that discharge notes do not include billing.

Navigating through the Document Editor

The above image features the Document Editor, including the treeview, seen at left.

The area within a data set where you enter the information to fill out the note is called the Document Editor. This area can be navigated in two ways, depending upon your preference.

1. Use the Navigation treeview to the left of your screen. This tree shows you all available sections for your note. Sections with a check mark indicate that they are included in this note-you can check and uncheck these to accommodate what you need to fully document on this patient.

2. The Next button at the bottom of each page in the editor will move you to the next section which is checked off in the treeview.

Active Data

Data will pull through from note-to-note within a case, beginning after the Initial Evaluation, which is called active data. This helps to cut down on repetitive data entry throughout the course of a patient's treatment. However, be sure to always read through the data carrying through and make changes as necessary.

Templates

The above image illustrated where to find the Document Templates in the top toolbar of the Document Editor.

Templates are used in initial evaluations to prepopulate information which is not patient specific to give you a jumpstart on your note. To view the available templates for your note, click Document Templates in the top toolbar of the Document Editor.

The above example shows several of our default templates.

Since templates can be used to pre-populate any section of your notes, different templates are created according to injury types. This enables you to pre-select measurements or tests which are likely to be relevant to the patient according to their situation. After you apply a template, you can add or edit the information within the editor to specify the patient's treatment and situation.

Templates are an excellent tool to increase your efficiency in documentation. Keep in mind, however, that applying a template will overwrite any existing data in the note.

Treatments

In TheraOffice, treatments are used to indicate the services provided to the patient, the minutes spent performing these, and the CPT codes used to bill for each specific services. For each session with a patient, you should update the treatments you performed with them and ensure that the minutes are correctly indicated to ensure a smooth billing process.

When adding a treatment to a note, you will notice that each of the columns drops down with additional options for that specific treatment.

You can use Protocols to group treatments together if you find that you often use specific groups of treatments that you would like to select easily. Use the Find button to view all available treatments in alphabetical order, or List to see all protocols listed out with their corresponding treatments. Use Progressions to set up a series of treatments that will change throughout the course of your treatment plan. (For example, if you are doing 2 sets of 10 for the first 3 visits, then 3 sets of 8 for the next 2.) You can use the arrow buttons to move treatments up and down throughout the list or the delete button to remove the treatment entirely. If you want to remove a treatment from this encounter, but would still like it to carry through in your Active Data, change the status of the treatment accordingly.

The image above showcases the evaluation complexity wizard.

**A note about 97001: In 2017, CMS introduced evaluation complexity codes to replace 97001. As a result, you must bill 97161, 97162, or 97163 in order to be paid for your evaluation services. To make it easier to select the correct complexity codes, TheraOffice templates are programmed to bill for 97001, which triggers an Evaluation Complexity Wizard to help you choose the correct code. If you prefer not to use the wizard, you can use the drop down in the CPT column of your evaluation treatment to choose your desired code. If you select a code incorrectly and would like to run through the wizard again, choose 97001 again in the dropdown menu. **

The above image shows a blank treatment window, as when creating a new treatment.

To add new treatments to your database, you will navigate to the Backstage Menu and click Documentation, then select Treatments. Name your treatment something that will make it easy to find when working in a note, then add in the default settings for that treatment. Settings can be changed from the default within the notes themselves, so choose the most common Settings for that treatment, rather than creating different settings for every possible scenario. Choose the type of treatment (ex: exercise, modality, manual technique.) Then, select the relevant CPT codes you would like to choose from when billing for this treatment. Set a default number of minutes. Finally, if the treatment corresponds with an exercise you would like to include in a home exercise program, link it to that exercise. Click OK to save.

Suggest Charges

The image above shows what the system has offered for Suggested Charges based on this insurance's fee schedule.

Suggesting charges is often the final step before finishing a note. While you can manually add your own charges if you wish (use the Add Charge button), the system is also built with a tool that takes the treatments, codes, and minutes you selected on the Treatments page and matches that information with the fee schedule for that insurance to recommend charges and modifiers to you.

To use the Suggest Charges tool, click the Suggest Charges button on the Charges table of the Charges page.

After suggesting charges, your relevant 59 and assistant modifiers, as well as MIPS charges will auto-populate in their respective boxes.

Locking Notes

Locking a note is done after the note has been completed and the provider has confirmed that all information within the note is correct. It is important that the note is complete and correct, as locked notes cannot be deleted or unlocked. Please see the Addendum section of this chapter if you have locked a note that was not complete or correct.

Locking notes is extremely important, however, as it is what pushes the charges from a note in Documentation to the corresponding Accounting visit, allowing that visit to be billed.

To help keep providers from falling behind on notes, only one unlocked note can be in a case at a time, so you should aim to complete and lock each note before you see that patient again.

There are two ways to lock a note:

The example above illustrates Option 1.

1. If you would like to generate a report from that data set, open the Document Editor and select Generate Document Report from the top toolbar. When you save that report, select one of the bottom two save options, both of which will lock the document data. This is the most common way to lock a note.

2. If you do not want to generate a report, you can lock the note from the patient navigator by highlighting the data set and selecting Lock Document from the top toolbar. Note, however, that Administrators typically require at least one report to be generated before locking the note.

Home Exercise Programs (HEP)

If you would like to give a patient a personalized home exercise program, you can generate one in a document report. To add a treatment to the patient's home exercise program, check off the treatment in the HEP column of the treatments page. Then, when you generate a report from that data, select Home Exercise Program.

If you would like to add additional exercises to your home exercise library, please see this help article.

Plans of Care

The above image shows the Treatment Plan section of a note in the document editor.

To generate a plan of care for a patient, be sure to fill out the Treatment Plan section of your note.

Then, when generating a report for the patient, choose either Plan of Care Style 1 or Plan of Care Style 2, depending on your preference. Each of these reports will include a section at the bottom of the report to be filled out by the physician to certify your plan. When the Plan of Care is certified and returned, we recommend uploading it to the patient's file as an image note.

The image above shows the Physician signature portion of a Plan of Care report.

Document Reminders can be used to help you to track these.

Document Designer

The above image shows the Reports tab of the Document Designer window.

The Document Designer is an extremely sensitive area of the software used to edit the formatting of information pulled from data onto reports. This tool makes it possible to fully customize the appearance and format of all of your document reports.

However, due to the sensitive nature of this area of the software, it is not recommended that users make adjustments here. If you would like changes to be made to your Document Reports, please contact customer support and a member of our friendly staff would be happy to assist you.

Addendums

If a note is locked with incorrect or incomplete data, it cannot be deleted or unlocked. However, in these special circumstances, you can create an addendum to your data.

If the mistake/missing information is minor, you can open the data and generate a new report. All reports are word processors, so you can add/delete information freely. Then, when you save the report be sure to include "Addendum" or "Corrected" to the title to indicate to yourself that the information in that report differs from what is in the data. Also, keep in mind that changing information in the report will not change your active data, so be sure to correct that error the next time you create a new note for that patient. If the changes you made in the addendum will affect billing, make sure to make the change in Accounting as well, or alert your biller.

If the mistake is larger, you may want to start a new note and make a copy of the data, effectively starting over. Correct the note as necessary. Then, use the Locked Documentation Data Mover Tool in Administrator to move the old data set into a Do Not Use Case. Be sure to delete the original Accounting visit as well, as locking a second note will create a duplicate.

**Note: You do not need to create an addendum if a note is locked with the wrong time, date, or rendering/submitting provider. All of these can be changed using Document Properties.**

Discharging a Patient

When you are ready to discharge a patient, you will want to fill out one of two notes:

-Discharge Note/Daily Note: This note allows you to document a patient's discharge when they have been seen on that day, as it includes a billing section in addition to discharge paperwork.

-Discharge Note: This note does not include a billing section. This note is perfect for discharges where you do not actually see the patient, but would still like to document a discharge, as when a patient self-discharges.

The image above represents where to find the Lock Case option in the top toolbar of the Patient Navigator.

Following your discharge note, you may want to lock the patient's case. This indicates that this case is resolved and you do not expect to schedule more visits with the patient for this issue. If the patient returns later and you would like to unlock the case and start documenting on the patient again, you can do so from the patient navigator. To lock/unlock a case, highlight the case name in the patient navigator and choose Lock or Unlock from the Case Options in the top toolbar.

The image above shows where to mark a patient as inactive in the patient information screen.

If you do not anticipate the patient returning to your clinic, you may want to also mark the patient as inactive. This will remove your patient from many reports, as well as separate their file from the active patients you are currently treating. If the patient later returns to your clinic, you can reactivate their file. To mark a patient as inactive, open their Patient Information and uncheck Is Active.

The above image showcases how to uncheck active patients when perusing patient lists.

If you need to reactivate a patient later, be sure to uncheck Active Patients Only when searching your patient lists.