PCP/VA Initial/ReExam SOAP Notes
6 min
Primary Care Physician Letters
Purpose
To communicate the patient’s initial visit findings and care plan to their Primary Care Physician (PCP), ensuring continuity of care and professional collaboration.
When
Complete after the patient’s intake has been entered and the provider has completed and signed the initial note.
Responsible Role
Chiropractic Assistant (CA) / Front Desk / Referral Coordinator
Procedure
Step 1: Print Initial Visit Note
- Open ChiroTouch.
- Select the patient.
- Navigate to:
- Clinical > Recent Encounters
- Select:
- Initial Visit
- Encounter Note has to be signed by Dr. Mays before printing
- Click Print.
Step 2: Fax Cover Sheet
- Send to: VA Medical Center
- Attention: VA Medical Doc
- Ref: Patient's VA Authorization
- Fax #: VA's fax number
Comment: Please review initial/reexam Soap notes
Step 5: Prepare for Provider Review
- Submit to the Doctor for:
- Review
- Signature Check
Step 6: Fax
once it has been faxed wait for Fax confirmation to print
- Scan confirmation report with documents faxed to VA
- Save as: Last, Frist - Initial Soap Notes to VA
- ReExam: L, F - DOS Soap Notes to VA
Step 7: Document Completion
- Open the New Patient Tracker.
- Document that:
- Initial was completed and faxed
- Include date sent
- ReExam - make a note in patient's Alerts & Notes with date it was faxed