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Physiotherapy bill format for Export

I'm going to show you guys how I create a hippos scribe documentation template specifically for thirdparty payer policy in this case we're going to do United Healthcare I'll show you the policy first this is it right here now this was updated July 1st 2024 they made some changes to how we expected to document time but I want to show you just kind of each of these elements and how you can create a documentation template in hippocrip so we're going to do treatment note session treatment session notes these are the required elements what I did is I took this I created a framework using chat gbt 40 and then I put that framework into the hippos cribe template I did this two different ways so one is I made each individual section so like treatment date then I came down I said specific interventions then I came came down to Accurate documentation so I basically broke each one of these required elements into its own section but then I also went in at the very bottom and I took the full framework so this full framework includes all of the required elements and I put it into one field so that depending on how you do documentation whether you're using an EMR whether you're using something like Google sheets or Google Docs or doing paper this will allow us to um kind of break this information up however we choose to use it I also created a self audit field so you can see here self- audit and basically I just said this is the UHC treatment session documentation policy make sure that each of these required elements are included and I said if I have the information there give me a check mark If I don't have the in information there uh give me an X so let me save any changes I might have made and let's just create a new recording so I'm going to come in here we've got the treatment note for UHC template scheduled and what I'm going to do is I'm going to start recording when I hit start I'm going to just dictate a note so we have something to go by and this is all fic fictitious information today's treatment date is July 5th 2024 I am the treating physical therapist Anthony maritato the specific treatment interventions we provided today included CPT code 97110 CPT code 97116 for CPT code 97110 We performed five minutes of cycling on the recumbent bike at level three resistance we perform formed 60 seconds of calf stretch on both the right and the left lower extremity 60 seconds of hamstring stretch on the right and left lower extremity hydraulic resistance knee flexion and extension two times 20 repetitions each for gate training CPT code 97116 We performed 15 minutes of walking the balance beam focused on heel midfoot toe off gate pattern We performed side stepping on the balance beam uh for two laps we performed multi-directional stepping through an agility ladder going forward and sideways the total intervention time for gate training was 15 minutes the total intervention time for therapeutic exercise was also 15 minutes the total treatment time in minutes was 30 minutes the individual's response to treatment was positive my patient reported a three out of 10 level of exertion my patient demonstrated a positive mood and felt increase motivation in his ability to walk without an assisted device my assessment of my patient ongoing progress toward goals today's treatment goal was to improve unassisted ambulation in the clinic my patient demonstrated improvement with reduction in loss of balance and a reduction in unsteadiness while walking without an assisted device my patient displayed increased confidence while walking and improved gate mechanics my patient displayed progress toward the goals in regards to being able to walk five laps of 25 ft each without a rest break and without assistance there were no problems or changes recorded to the plan of care my patient reported being compliant with home exercise program performing them twice daily as prescribed I'm signing off on this treatment note today July 5th 2024 okay so what I did was I used the provided framework to guide my dictation of that treatment note now it's rendering let's see what this ends up looking like okay so I you know I'm still getting better at this um sometimes I go back and forth sometimes I lose focus especially because I'm trying to teach you guys what I'm doing how I'm doing it but we've got the treatment note we've got specc specific interventions uh theraputic exercise 15 minutes recumbent bike for five minutes level three calf stretch one minute right and left hamstring stretch one minute right and left hydraulic knee extension flexion um now I said times 20 but this went to 40 so I'm just going to switch it gate training 15 minutes balance focus on heel midfoot toe off gate pattern I said this and I realized when I said it I said we did that for 15 minutes um but that's not correct that would normally be two laps side stepping on balance beam two laps Agility Ladder multi-direction stepping two laps you know 15 minutes of of gate training total treatment time in minutes 30 minutes individual response to treatment Patient responded positively to interventions reporting three out of 10 level of exertion patient demonstrated positive mood increase motivation walk without an assisted device these are all things that were you know dictated recorded and transcribed here um skilled ongoing assessment of individuals progress toward the goals see these are important elements for compliance with the United Healthcare requirements and it says patient required expert supervision for balance beam walking side stepping multi-direction unassisted ambulation therapist assessed the patient showed significant progress in reduced loss of balance therapists noted the patient was able to walk 25 fet so that's great that satisfies that required element all progress uh treatment goal improve unassisted amb ation and Clinic measurable progress demonstrated reduce loss of balance while walking reduce unsteadiness without assisted device increase confidence able to walk five laps 25 fet each perfect any problems or changes no problems or changes with the plan of care reported member involvement patient reported being compliant with home exercise program twice daily and then signature and treating provider now this is where it kind of goes off off the rails a little bit literally all you would need is treatment date and clinician you don't need the rest of this information okay the self audit so now let's take a look at what we got we've got the treatment date we've got this we've got this this this everything is included um I love these self- audit features that we can put into hippos scribe to check what we put into our documentation and then the other version now now technically everything you just saw is a standalone you know that's the way it would function if you have the integration like this will integrate with hello note this will integrate with um multiple emrs I can open the um browser extension right here and I can kick it over into the EMR but the other option is if you're doing custom documentation on something like Google Sheets Google Docs whatever ever we want to come in here now notice I never said the patient's name I never said a patient's ID because this is not a real patient but if I did it would be documented there so we have all of the required elements I didn't indicate start and stop time but I did indicate total treatment time in minutes um so something that's a little bit off here it's got these like treatment one two three it's trying to put those interventions together but it's not really doing it correctly it did it well up here probably because I have a better example in the template so that would be something from a template generation perspective that I want to change the way I have the example written out because that's not really going to work like it's just not um um but you know this this is something that once I tweak it a little bit I can copy it I can paste it over into a Google doc and this is a completed uh treatment note that is compliant with UHC requirements so this this tool this template is available in hello note um if you guys want to take it adapt it I will also include the link to the United Healthcare update policy so you guys have that available if you want it otherwise I wish you the best I'm going to keep cranking out these videos and tutorials so you can see what the functionality is like if you're going to use hippos scribe for your documentation