It is possible to create highly specific SOAP Note Templates to meet an insurance carrier's requirements. Below is an example of what an enhanced SOAP Note Template would look like and how to build it. For this example, we created an Enhanced SOAP Note Template to use only when charging CPT 97153 at a patient's home (POS 12). You can create as many templates as you need to help your therapists stay in compliance with a specific insurance carrier or situation.
For more information on creating SOAP Note templates, see Create SOAP Note Template.
The information below is automatically included in SOAP Note Header when generating a PDF copy of notes. So, users do not need to add this information to their template or SOAP Notes:
- Client’s full name (Comes from client demographics)
- Client’s date of birth (comes from client demographics)
- Age (comes from the client’s date of birth)
- Client’s diagnosis/codes: Comes from client demographics
- Length of session: (Based on start and end time entered in SOAP note)
- Rendering provider’s full name and credentials (Pulls from User’s information in the admin portal of who is logged into the app and writing the note)
- Name of Authorized ABA Supervisor and Credentials: (Pulls from BCBA drop down in demographics and from user’s information in the admin portal)
- GPS location of rendered services (if you have location services turned on your device you are writing the note on)
Below are the fields we used when creating this example SOAP Note Template. This will show what Answer Type you would need to choose for each section, what the content would be in each section, and if it should be required or not. You can also re-order your SOAP Note Template fields while creating them to be in the order below.
NOTE: Again, this is just an example of a very specific, detailed SOAP Note a payer may require and not a specific recommendation of this example template.
This table outlines each field to add in order to recreate the above example template.
| Answer Type | Content | Required (Yes/No?) |
| +Add Note | Treatment CPT Code: 97153 Adaptive Behavior Treatment by Protocol | N/A Just text in the note |
| Date Picker | Date: Automatically added by the system | Yes |
| Time Picker | Start Time: Automatically added by the system | Yes |
| Time Picker | End Time: Automatically added by the system | Yes |
| N/A | GPS Location: Automatically added by the system | No |
| Multiple Choice (Static List) | Entry Text: Place of Service Code Comma-Separated Choices: 02 Telehealth,03 School,11 Office,12 Home,99 Other Place of Service | Yes |
| Free text | Entry Text: Name of Session Participants (Excluding Other Beneficiaries) | Yes |
| Multiple Select (Static List) | Entry Text: Patient's Current Clinical Status Evidenced by their Signs and Symptoms Comma-Separated Choices: Engaged and responsive to staff, Engaged in maladaptive behaviors, Communication skills deficits, Social skills deficits, Restrictive/repetitive behaviors, Adaptive skills deficits, Transitioned successfully to the learning environment, Refusal to transition to the learning environment | Yes |
| Free Text | Entry Text: Additional Information on Patient's Current Clinical Status | No |
| Multiple Select (Static List) | Entry Text: Objective (Techniques Attempted During the Session) Comma-Separated Choices: Antecedent Interventions, Discrete Trial Training, Natural Environment Training, Differential Reinforcement, Extinction, Prompts/Prompt Fading, Functional Communication Training, Reinforcement Procedures, Behavioral Momentum, Errorless Teaching, Pivotal Response Training, Task Analysis, Shaping, Generalization, Maintenance, Other (summarized below) | Yes |
| Free Text | Entry Text: Other Techniques Attempted During the Session | Yes |
| Free Text | Entry Text: Assessment (Description of Response to Treatment, The Outcome of the Treatment, and the Response to Significant Others) | No |
| Free Text | Entry Text: Plan (Patient's Degree of Progress Towards Treatment Goals/Plans for Any Modifications Needed To Address Progress) | Yes |
| Multiple Choice (Static List) | Entry Text: Summary of Progress Towards Current Treatment Goals Comma-Separated Choices: Exceeding Expectations, As Expected, Delayed | Yes |
| Multiple Choice (Static List) | Entry Text: Were Parents/Caregivers Present During the Session? Comma-Separated Choices: Yes, No | Yes |
| Multiple Choice (Static List) | Entry Text: Did Parents/Caregivers Participate During the Session? Comma-Separated Choices: Yes, No | Yes |
| Multiple Choice (Static List) | Entry Text: Did the Provider Render Services in accordance with the BACB Guidelines for Responsible Conduct for Behavior Analysts? Comma-Separated Choices: Yes, No | Yes |
| Free Text | Notes: Automatically added by the system | No |
| Signature | Entry Text: Signature of Rendering Provider | Yes |
| Date Picker | Entry Text: Date Signed by Rendering Provider | Yes |
| Signature | Entry Text: Signature of Authorized ABA Supervisor (If applicable) | No |
| Date Picker | Entry Text: Date Signed by Authorized ABA Supervisor (If applicable) | No |
| Free Text | Entry Text: Guardian/Caregiver Name | No |
| Signature | Entry Text: Guardian/Caregiver Signature | No |
| Date Picker | Entry Text: Date of Guardian Signature | No |
IMPORTANT: Disclaimer: This training may contain suggestions and best practices with respect to how to use our product. You acknowledge and agree that Ensora Data Collection is not a healthcare provider. You understand and agree that the responsibility for medical treatment rests with healthcare providers. In the event that information from this training is used in connection with any diagnosis or treatment, you assume and accept all liability for such diagnosis or treatment. You agree that the sole and exclusive responsibility for any medical decisions or actions with respect to a patient’s medical care rests with the healthcare provider. The ultimate choice with respect to when and how to use your product is your responsibility. Nothing in this training is intended in any way to suggest any procedures, medication, or physical findings for the patient or eliminate, replace, or substitute for, in whole or in part, a healthcare provider’s judgment and analysis of a patient’s condition.