Skip to main content

Write a re-evaluation

Use a re-evaluation to document a reassessment of the patient's condition and treatment needs. A re-evaluation can continue the current treatment plan or establish a new plan.

Before you start​

Review:

  • the current plan of care
  • patient progress toward goals
  • remaining deficits
  • medical necessity for continued skilled therapy
  • whether the current treatment plan still reflects the patient's needs
  • the proposed frequency and duration if you plan to establish a new treatment plan

Complete the re-evaluation​

  1. Open the patient's therapy case.
  2. Click Re-evaluations.
  3. Click New re-evaluation.
  4. Enter the re-evaluation date and complete the clinical documentation.
  5. Under Treatment plan, choose one of the following:
    • Continue current plan to keep the active treatment plan, including its original end date, frequency, duration, and anticipated interventions.
    • Create a new plan to enter a new start date, frequency, duration, and anticipated interventions.
  6. Review the treatment-plan summary or enter the new plan details.
  7. Save the re-evaluation.

Continue the current treatment plan​

Choose Continue current plan when the re-evaluation supports continued care under the existing plan. This can be useful when a therapist needs to perform and bill a re-evaluation using the appropriate re-evaluation CPT code without changing the patient's treatment frequency, duration, or anticipated interventions.

This option is available only when a treatment plan covers the re-evaluation date. Continuing a plan does not restart or extend it. The plan keeps its original end date.

After saving​

Route the re-evaluation for signature if required by your organization or payor workflow.