Digital Patient Intake: SOAP 1.0 Integrated Fields

When a patient completes their Digital Patient Intake, certain fields from the Medical section will automatically populate into the patient's SOAP 1.0 Initial Evaluation. This article shows the question in the patient's intake form and how it appears in the SOAP note.

Date of Injury

The “Approximate Date of Injury” field within the “Tell us about your injury and/or symptoms” question will populate in the Subjective tab in SOAP 1.0. The patient’s response will show up in the Patient Presentation subsection, under Injury/Onset Date/Change of Status Date.

Medical Conditions

Patients will have the opportunity to select the medical conditions they are being treated for (or have been treated for in the past) on sequential pages in the intake form. The intake form lists several options (see images below) for the patient to select. Selected conditions will populate the Subjective tab within SOAP 1.0 in the Medical History Subsection under Medical History

Note: Conditions without a 1:1 match in from the intake form to SOAP 1.0 will populate the “Other” field.

Pain Location, Type, and Scales

There are three questions related to pain scales that show in the Pain Scale subsection.

  1. The response to “What region(s) are affected by your current symptoms?” displays in the Pain Location field. 
  2. The response to “Please indicate the intensity of the current, best, and worst pain levels over the past 24 hours on a scale of 0 (no pain) to 10 (worst pain imaginable)” will populate accordingly in its corresponding Pain Scale field for the At Worst, Current, and At Best.
  3. The response to “What kind of pain are you experiencing?” will populate in the Pain Description field. 

Note: For types of pain selected other than “Numbness/Tingling” the “Custom” dropdown will be utilized.

Current Medications

If the patient answers “Are you currently taking any medications?” question with “Yes”,  then the patient is prompted “Please list any current medications. Use the plus sign to add each medication.” These responses will be added to the Current Medications subsection. 

Note: Medication name and dosage provided by the patient will be comma delimited for each entry. Each additional medication will be separated by a semi-colon.

At the time of limited release, a defect was identified where the “Current Medications” field does not carry over from the intake form. The fix is in progress and this notice will be removed when it has been deployed. Please confirm current medications with the patient. 

Therapy Goal

The patient response to “What are your goals for therapy at this time? (free response)” displays under Patient Goals in the Patient Presentation subsection.

Integrated Field Mapping at a Glance

Theme Integrated Intake Form Fields and Prompts - Medical Section SOAP 1.0 Location - Subjective Section
Date of Injury Approximate Date of Injury Basic Info > Injury/Onset Date/Change of Status Date
Medical Conditions Please select the conditions that you have been or are presently being treated for. This information helps your therapist develop a treatment plan that will be best for you. Medical History > Medical History
Pain Location What region(s) are affected by your current symptoms? Pain Subsection > Pain Scales > Pain Location 
Pain Type What kind of pain are you experiencing? Pain Subsection> Pain Scales > Pain Description
Pain Scales Please indicate the intensity of the current, best, and worst pain levels over the past 24 hours on a scale of 0 (no pain) to 10 (worst pain imaginable). Pain Subsection > At Worst, Current, At Best
Current Medications Please list any current medications. Medical History > Current Medications Subsection
Therapy Goal What are your goals for therapy at this time? Patient Presentation Subsection > Patient Goals

Importing Intake Information into an Existing IE 

If a patient completes intake after the therapist has saved information in that Initial Evaluation, eligible fields (provided the fields were filled out by the patient) in the intake form will not be automatically added over the existing information.

Instead, the therapist will be prompted to either accept or deny the updates from the intake form when they re-open the note. 

If changes are denied, no fields will be updated or changed in SOAP 1.0.

If the changes are accepted, the following notification will be displayed, indicating how many fields (out of the seven available) were added and that information will now appear in the IE. 

If any fields were changed by the therapist or had data entered previously by the therapist, those fields will not be imported. 

For example:

  1. The therapist has filled out the date of injury in the IE. 
  2. The patient submits their intake form with a different date of injury. 
  3. Upon opening the note again, the therapist is asked if they want to import fields from intake, and says yes. 
  4. The date of injury that displays will be the original date the therapist had input, and would not update to what the patient submitted through the intake form. 

Seeing the green prompt but not seeing the expected fields populate? Please reach out to support@webpt.com.

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