Evaluation Process

Admission Documents

You will only need to complete Admission Documents if you are the first Solace clinician in the home.  Please see the Admission Documents Page for more detailed information.

Visit Note

• All Clinicians may complete the following note type:  ST/OT/PT Pediatric Initial Eval 

  • Case Managers will also include the following in the “Interventions/Goals Additional Notes” section of the note:

    • In the Interventions - Additional Note box: Insert "reviewed medications with family at SOC." and the patient’s Medication Interaction Statement

      • See here for more information about how to update a patient’s medication profile if the family indicates the patient is taking medications or supplements

    • In the Goals - Additional Note  box: Paste the assessment portion of your Narrative from the end of your note here.

    • Completing both of these steps will allow this information to automatically populate into your Plan of Care

  • REMINDER: Please do not CLOSE your note until you have created your Care Plan, so that your goals and interventions pull into the note for a complete Initial Evaluation!

Care Plan

The Care Plan is a section of the medical chart where we add the Problems, Interventions and Goals that we plan to address through therapy.  During the initial evaluation process, the Care Plan should be created prior to closing the Initial Visit Note in order to allow the information to pull into the note.  The start date of all problems, interventions and goals should match the initial evaluation date.

Orders

Orders outline the requested frequency of services for your discipline AND schedule out those visits for 60 days in the Service Calendar so that you are able to document visits.  In addition to a weekly or monthly visit frequency, we also include a request for PRN visits to allow scheduling flexibility for make-up sessions when needed.

• If you are case manager/1st clinician in the home, at initial evaluation you will complete Plan of Care Orders.  

• If you are the 2nd or 3rd clinician to complete an evaluation, at initial evaluation you will complete Verbal/Request Order.  This is the only time we complete this type of order.

Please see the video and flow sheet support below on how to enter each type of order.

Plan of Care Document

If you are the Case Manager, your final step of the evaluation process will be generating a Plan of Care Document.  This document pulls together the full plan of care including info from the eval note itself, your interventions and goals, orders and other required information to be signed off on by the prescribing provider- which gives us the ongoing okay to provide services.  Please see the flow sheet below on how to generate a Plan of Care Document at Initial Evaluation.