Clinical documentation¶

Clinics that switch on clinical documentation (tenant flag clinicalDocumentation) write their visit notes in Otera (OKTA in Russia), tied to everything the platform already knows about the patient: the intake, the home program and what the patient reported after sessions, the measurements of the clinic's own camera and sensor tests, the outcome scores, a video visit's notes and transcript, and what the therapist typed or dictated during the visit. A note is one of six kinds (initial evaluation, treatment note, progress note, re-evaluation, recertification, discharge summary), belongs to a plan of care with goals that every later note reports on, can start from a template, gets its first draft from AI on request, is signed and locked, and, where the clinic bills, becomes a claim in the claims portal. The patient's referral and the documents that came with them live on the same tab, questionnaires go to the patient's phone, and a signed evaluation hands its picture to the home-program builder. The Medicare rules a plan of care is held to are built in and shown where they matter.

Everything here is additive: a clinic without the flag sees none of it, and nothing changes in plans, sessions, messages or the existing notes feed. A clinic that switches the flag off again keeps its signed notes: they stay in the record and in the patient's Notes feed, but the pages and the actions disappear and no reminders go out.

For the therapist¶

Starting a note¶

A note opens from wherever the visit is:

From an appointment: the appointment's sheet (web and app) has Start visit as its one step before the visit, for the visit's own therapist: it checks the patient in, starts the visit and opens the note, in the app with the timer running (an administrator on a colleague's visit checks the patient in; the note stays the treating therapist's). A visit already completed offers Start note; afterwards the sheet reads Open note · Draft or · Signed. The Today list in the app says "Note to sign" or "Note signed" on each visit.
From a video visit: the visit's review offers Document this visit, next to "Save to patient's notes", which keeps working as before.
From the patient's chart: the patient window's new Documentation tab (and the Notes screen in the app) lists the visits without a note with Start note on each, and New note for a visit the calendar does not know. Where the clinic has the flag, Documentation is the patient window's first tab and the one it opens on, and Notes is the first of the patient's actions in the app.
From the worklist: the dashboard's Documentation tab lists the visits of the last two weeks without a note, and its New note button asks for the patient, then opens the same type-and-date sheet with the suggested kind already chosen.

When the patient has a booked visit that day without a note, checked in or not, New note (on the web and in the app) asks which visit it is for and picks the first; "Not for a booked visit" writes it on its own. A note for a visit takes the visit's times and kind, and signing it completes the visit, so the visit does not stay under "visits without a note".

A visit has one note. Starting it again opens the existing one; a note a colleague already started is named rather than duplicated. A cancelled or no-show visit, and a sample patient, get no note.

For an evaluation, a re-evaluation or a recertification, New note also asks which case the plan treats, when the patient's record holds an operation or an injury: the note, the chart and the app then say how long it has been ("6 weeks after surgery · Total knee replacement, Sep 9"), and the draft reads it. A note can be written without a visit (a discharge for a patient who did not come back, say): it has nothing to bill and does not count as a visit. The last step of New note offers a template (see below).

The kind of note is suggested and can be changed until signing: the first note of a patient without a plan is an initial evaluation; an appointment booked as an evaluation, a re-evaluation or a discharge visit gets that kind; a progress note is suggested when one is due this visit or the next (where the Medicare rules apply); otherwise a treatment note. The date of service is the day of the appointment or the video visit (changeable, never in the future); the appointment's start and end fill in the visit's times, or the app's timer does. The note opens with what the plan of care already holds: the diagnoses, the precautions and, for an evaluation or a re-evaluation, the terms.

The six kinds¶

Kind	When	What it holds	Before it can be signed
Initial evaluation	The first visit of an episode; it opens the plan of care	History, subjective, objective, treatment, assessment, plan, precautions; pain; measurements, special tests and strength; diagnoses; the goals; the evaluation card (complexity, how often and for how long as a number or a range, interventions, prognosis, rehabilitation potential)	The history, the examination findings, the assessment and the plan written; at least one diagnosis; how often and for how long; at least one goal; the complexity where the clinic bills
Treatment note	Every visit	Subjective, objective, treatment, assessment, plan	The assessment and the plan written, and what the patient reported or what was found
Progress note	At least every tenth visit (see the Medicare rules)	A treatment note plus the progress card: how the patient progressed against the goals, and why skilled care continues; a status and a line for every open goal	As a treatment note, plus the progress summary
Re-evaluation	When the plan changes	Everything an evaluation has plus the progress card; it bills 97164	The examination findings, assessment, plan, a diagnosis, the terms, a goal, the progress summary
Recertification	When the certified period is about to end: suggested from 14 days before the end and after it, until one is signed	A progress note plus the terms for the next period; signing writes the terms to the plan. A certification that still runs stands, and the signed note goes to the physician; once it has ended (or none was certified), the next period opens on the plan, pending the physician's certification	As a progress note, plus the terms
Discharge summary	The last note; it closes the plan of care	Subjective, objective, assessment, plan, and the discharge card: the reason (goals met, plateau, the patient's choice, lost to follow-up, medical, moved, other), the status at discharge, the instructions	The assessment and the plan, the reason, and a final status for every open goal

The checks sit beside the Sign button, the first one under it, so there is nothing to guess. A few points only warn and never block: no diagnosis marked as primary, a treatment note that does not say what was done, a progress note without the justification, an open goal without a status in a progress note, a discharge without instructions, and the coding warnings below.

Every kind also carries a Pain row (now, best and worst on 0 to 10, and where), Measurements and Findings (see below), and, at the top, Your notes from the visit: whatever was typed or dictated during the visit (in the app or on the page), kept apart from the note itself and read by the draft.

On the evaluation card, how often and for how long can be a range ("2 to 3 times a week for 4 to 6 weeks"; the upper bound sets the planned visits), and the rehabilitation potential is picked from excellent, good, fair and poor. A note can be marked as having no services to bill, with the reason (not a visit, self-pay, pro bono): its service lines go, it stays out of To bill, and it does not count as a visit for the Medicare rules.

The plan of care¶

An episode of care has one plan, opened by the initial evaluation (or made from the chart before the evaluation is signed) and closed by the discharge summary. It carries the diagnoses (ICD-10-CM, the primary first), the problem list, the terms ("2 times a week for 6 weeks", and how many visits that is), the planned interventions, the precautions, the prognosis, and the certification by the physician: Pending, Sent (Mark as sent to the physician) and Certified for a period (Mark as certified, with the dates; 90 days from the start by default, as the clinic sets). The plan is edited from the patient's Documentation tab; signing an evaluation or a re-evaluation writes the note's terms, diagnoses and precautions to it, and an evaluation sets the period the physician is asked to certify. Signing a discharge closes the plan and discontinues the goals still open; the chart lists the past plans under the current one. A new initial evaluation for a patient who already has a plan opens a plan of its own; until that evaluation is signed, the current plan stays the patient's plan (its notes, its visit count and its rules), and the goals and scores written in the new evaluation go onto the new plan.

Goals¶

Goals belong to the plan: short-term or long-term, with the baseline ("LEFS 32/80"), the target ("LEFS 60/80"), a target date and a status (in progress, met, partly met, not met, discontinued). They are written in the evaluation (AI proposes them in full, SMART: the function, the baseline, the target and the number of weeks, which becomes a target date counted from the date of service; Add the goals is ticked in the draft's proposals), edited in the chart, and reported on in every progress note, re-evaluation and discharge: each open goal gets a status and a line, which signing writes to the goal. A goal a signed note reports on is never deleted, only discontinued. A plan holds up to twenty.

Outcome measures¶

Add a score records a standard measure on the note or in the chart, as a total or, for the questionnaires, item by item (the answers are kept with the score):

Instrument	Score	Entered	Meaningful change (MCID)
LEFS (Lower Extremity Functional Scale)	0 to 80, higher is better	Item by item; one skipped item is scaled	9
ODI (Oswestry Disability Index)	0 to 100 %, lower is better	Item by item, as a percentage of the answered items	10
NDI (Neck Disability Index)	0 to 50, lower is better	Item by item	7.5
QuickDASH	0 to 100, lower is better	Item by item	8
PSFS (Patient-Specific Functional Scale)	0 to 10, higher is better	Up to five activities rated 0 to 10, averaged	2
NPRS (pain, 0 to 10)	Lower is better	Total	2
Timed Up and Go	Seconds, lower is better	Total	None published; the change is shown
6-minute walk test	Meters, higher is better	Total	50
Five times sit-to-stand	Seconds, lower is better	Total	2.3
Berg Balance Scale	0 to 56, higher is better	Total	6

Every later score of the same instrument shows its change against the first one of the plan and whether it reached the instrument's MCID (a meaningful chip). The note shows the scores recorded on it and the patient's latest per instrument; the chart shows the whole series. A score on a signed note stays in the record. The list keeps patient questionnaires and performance tests apart, and on a progress note, a re-evaluation, a recertification and a discharge the scores come first, where the progress is judged.

Ask the patient sends a questionnaire to the patient instead of reading it out: they answer it on their phone (the app's dashboard lists what is waiting) or from the emailed link without signing in, a few taps, and the score lands on the chart as theirs, with the change since the first one. The questionnaire that fits the diagnosis is marked as recommended (LEFS for the knee, hip, ankle and foot; ODI for the low back; NDI for the neck; QuickDASH for the shoulder, elbow, wrist and hand), and the clinic can have it sent on its own: with the intake, due by the first visit, and when a progress report is due this visit or the next. A questionnaire not answered after three days is reminded once, in the clinic's daytime; one asked again within two weeks of the last is not sent twice. Only a questionnaire can be asked of the patient: the timed and counted tests (TUG, the 6-minute walk, five times sit-to-stand, Berg) are measured at the visit. A waiting one can be withdrawn from the chart.

Measurements from the lab¶

The camera and phone-sensor tests the patient did (in the clinic with the therapist's phone, or at home as a screening) are offered to the note: the peak range of motion of every completed test since the last signed note (or the last 60 days), one row per side, with its source (camera or phone sensors) and date. Import from the lab puts the chosen rows into the note's findings, where they print under Measurements. The app lists what will be offered.

Findings: special tests and strength¶

Findings on the note hold the special tests performed (from a catalog by region, or typed by name) with the side, the result (positive, negative, inconclusive) and a line, and the strength of muscle groups as manual muscle test grades (0 to 5, with the pluses and minuses) per side. A group a template listed waits for its grade: picked in place on the draft, "not graded" on a signed note, and pointed out before signing. They print under the objective findings. The draft fills them from what the sources say and never invents a result; a template lists the tests and groups to examine for its region.

The referral and the documents on the record¶

The patient's Documentation tab carries the referral (the script). Drop a PDF or a photo of it, or photograph it in the app: AI reads the physician's name and NPI, the date, the diagnoses, how often ("2–3 a week" keeps both numbers) and for how long, the visits authorized, the expiry and the restrictions, and the therapist checks every field against the paper before saving; nothing is guessed, what could not be made out is listed, and a diagnosis named in words without a code is pointed out so the code can be found. The confirmed referral goes onto the plan of care's empty fields (diagnoses, how often and for how long, the physician) and, where the clinic bills, onto the claims portal's referring provider, with one click or as part of saving. A patient who came on their own is marked Came without one (direct access): the draft then knows to propose the treating diagnoses from the findings. The draft reads the referral in words, and a diagnosis on the referral counts as on record before it is put onto the plan.

Documents keeps whatever came with the patient on the record, as a PDF or a photo (an iPhone's HEIC included): the script, a physician's report, the surgeon's protocol, the insurance card, anything else. They live in the clinic's own private storage, open in a new tab through a link that works for ten minutes, and can be removed. The text of a PDF report or protocol is read by the draft. Where the clinic bills, Photograph the insurance card reads the card into the patient's insurance for claims, the same way the intake does, and keeps the photo on the record (a clinic without the claims portal has no such button, and the referral goes onto the plan only). In the app, the same from the patient's Notes screen, with the camera.

The AI draft¶

Draft with AI writes the first version of the note from what the record holds: the intake summary, the last two signed notes, how the home program went since the last note and what the patient reported after sessions (pain, exertion, their own words), the lab's measurements, the outcome scores, a video visit's note, live notes and the therapist's own notes from it (the transcript when there is nothing else), and the notes typed or dictated during this visit, which win where the sources differ. It takes ten to forty seconds; the empty sections show as lines being written meanwhile.

The draft writes itself when the visit ends, where the clinic has that on (Write the draft when a visit ends, on by default): when the app's timer stops, when the visit is marked completed on the calendar, or when a note is opened for a visit already completed, the draft is written in the background and the note says so (the empty sections as lines being written, on the web and in the app) until it lands. While it is written the note cannot be signed or drafted again, so nothing the therapist has not read is signed. Draft with AI and Draft again stay for a clinic that switched it off, or for a second version. A timer stopped and started again keeps the first draft; Draft again writes it anew.

The draft fills what is empty and never overwrites what the therapist typed unless asked (Draft again with overwrite what I typed). Beside the note it proposes, as one-tap chips: the diagnoses the record already names (they go onto a note that has none), the services it saw given (never the minutes), updates to the goals, new goals for an evaluation, the evaluation's complexity, the terms, the planned interventions, the prognosis and the rehabilitation potential, a plain-words summary for the patient, the red flags (new numbness or weakness, a fall, a sudden worsening) and the points to verify (a side not stated, a number it could not make out). Every number is kept exactly as given; a section with nothing to report says so in a sentence. It also reads the referral and the physician's reports and surgeon's protocol on file.

For a patient who came without a referral (no diagnosis on record), the evaluation's draft proposes the treating diagnoses that fit the findings. These are marked as AI's own reading, not the record's, and sit beside the note as chips to verify; they never go onto the note by themselves. The same goes for the terms it proposes.

Templates¶

A note can start from a template, offered as the last step of New note and from the rail beside a draft: the built-in starter set (evaluations for the knee, the hip, the shoulder, the low back, the neck and the ankle; a treatment note; a progress note; a discharge summary), the clinic's shared templates and the therapist's own. A template fills what is empty: the sections' text, the terms, the special tests and muscle groups to examine (the groups come without a grade), the questionnaires to collect (offered as chips on the note until scored), the services and the goals; what the therapist already typed stays. A built-in names no service: what was done is documented at the visit. Save as template keeps any note's structure as the therapist's own, with a name and a region, and can share it with the clinic; only its owner deletes it. The sections come over as their headings with an empty bracket to fill ("Onset: []"), never with what was written about the patient; the terms and the planned interventions (not the prognosis), the tests, the strength groups, the service codes (without their details) and the goals come over as they are. The built-in set is in English and in Russian, in the language the clinic's notes are written in. A clinic holds up to 100. On a draft, each section can also be copied from the last signed note with one click.

The home program from the note¶

A signed evaluation, re-evaluation, progress note or recertification offers Build the home program (Update the home program on the later kinds). It opens the dashboard's home-program builder for the patient with the note's clinical picture already in the notes box: the diagnoses, the case, the terms, the precautions, the pain, the measurements, the strength and the special tests, the scores, the history, the findings, the assessment and the plan, the planned interventions and the open goals with their targets. The AI plan generator starts from that, and the therapist edits from there.

The note, the chart copy and the app say in words what it was drafted from: "Drafted by AI from the intake, the last note, 9 sessions and 4 measurements". Inside the Draft with AI card, above the button, What the draft reads lists what is there to read before asking. The intake line names the intake the draft will use, or says why one is left out: sent more than 90 days before the visit (and not for this visit), or without a summary to read. Show opens the patient's intake beside the note. An initial evaluation also says at the top, next to the visit number, whether there is an intake to start from. Without an OpenAI key on the server, notes are written and signed by hand and the button says "AI is not set up on this server".

Coding and the 8-minute rule¶

Where the clinic bills (the claims portal is on), the note has a Services panel; elsewhere it has a plain Treatment narrative and no codes.

Each line is a CPT code (picked from the catalog grouped as evaluation, therapeutic, manual, modality and other, or typed; a code the catalog does not know is billed by the units typed), the minutes for a timed code or the units for an untimed one, the modifiers as toggles (GP on by default, KX, 59, XU, 95, CQ, GA), which of the note's diagnoses the line points at, and a detail line ("Squats 3 x 10"). The units of timed codes are worked out on the server as the minutes are typed, and the footer says so: "40 timed minutes → 3 units", with the charge where the clinic's fee schedule knows the codes.

The 8-minute rule, in plain words: a timed code is a 15-minute service, and the minutes left over count as a unit only from 8 minutes. Medicare's way (the default) adds up the visit's timed minutes first: 8 to 22 minutes bill 1 unit, 23 to 37 bill 2, 38 to 52 bill 3, and so on, and the units are then spread over the codes by the minutes each took, the full 15-minute units first and what is left to the longest remainders. So 33 minutes of exercise with 7 minutes of manual therapy is 40 minutes and 3 units, 2 and 1, as the Medicare manual's own example has it. The AMA's way (a clinic setting) counts each code on its own: a unit per 15 minutes plus one for a remainder of 8 or more.

An evaluation's complexity (low, moderate or high, chosen on the evaluation card with the criteria in one line each) sets its code, 97161, 97162 or 97163, and the line follows the choice; a re-evaluation bills 97164. The checks: one evaluation code per visit, minutes on every timed line, at least a unit on an untimed one, every line pointed at one of the note's diagnoses, and a diagnosis on a billed visit. Warnings: an evaluation without its code, an evaluation code on a later note, a video visit's line without modifier 95, a code twice on one visit, and a code under 8 minutes alone.

Signing¶

Sign is the one primary button on the note; it stays off while a check blocks it. It opens the attestation ("I attest that this note is accurate and the services were provided as documented.") as text over the one Sign button, with the signature as it will print, the therapist's name and credentials ("Anna Petrova, PT, DPT"), so the signature is one click. The credentials are set once, under Profile › Signature (web and app) or in the sign sheet the first time, and kept; a therapist with them set is not asked again. Where the draft wrote the after-visit summary, the sheet also offers Send the summary to Anna when I sign: switched on, it shows the whole summary, labelled as written by AI, and sends exactly that text; the switch remembers each therapist's last choice on that browser or phone. A signature that changed nothing on screen but finds the note changed on the server (a draft that landed meanwhile) is refused, and the note is shown again to read. Signing:

freezes the note with a fingerprint of its content; an editor that is out of date is refused and asked to review;
puts the signed note into the patient's Notes feed as a read-only chart copy with a Signed note chip and Open; it cannot be edited or deleted there;
writes the evaluation's or re-evaluation's terms, diagnoses and precautions to the plan of care, and a discharge closes the plan;
gives the goals the statuses the note reports;
completes an appointment still checked in or in progress;
updates the billing diagnoses the claims portal uses (an evaluation, re-evaluation or progress note with diagnoses);
and, where the clinic bills, lists the visit in Claims › To bill. The note then says Ready to bill from Claims › To bill, later "On claim #12 (Sent)".

The headings of the signed copy follow the clinic's language (English, or Russian on OKTA). Only the author edits and signs a draft; a colleague who may see the patient reads it. A draft with nothing in the way is also signed in the app, with the same attestation and the summary switch, and with the services the note bills and its warnings listed in the sign sheet (the app's note screen does not show them otherwise); one that still has blockers names them in the app and is finished on the web (Open in the web app). A note whose kind differs from the visit's (an evaluation on a visit booked as a follow-up, or the reverse) says so at the top, and New note warns when an evaluation for the patient was already signed that day. Once the note of a booked visit is signed, the page offers the next visit (see scheduling.md): the same time next week (a follow-up after an evaluation), the whole plan of care after an evaluation with terms, or another day; a signed discharge offers none.

Amendments¶

A signed note is never edited; it is amended, and the history is complete. Amend offers three kinds, each signed with the amending therapist's name and the time: an addendum (text added, and with it what was found later: an outcome score, a measurement, a special test, a strength grade, a goal's status), a correction (a section's text replaced, or the pain scores, the measurements, the findings, the diagnoses, the terms, the discharge card or, while no claim carries the note, the services; the original is kept and shown as before and after; corrected terms, precautions or diagnoses on the plan's latest evaluation, re-evaluation or recertification also update the plan of care, as the signature did), and entered in error, which voids the note: it stays in the record, read-only, under a banner saying who voided it and when, and nothing else of it is used. A note whose services are on a claim cannot be voided until the claim is voided. A voided note lets go of its visit, so the appointment or video visit shows again among the visits without a note and can be documented again. Voiding an evaluation or a discharge detaches it from the plan (a voided discharge reopens the plan, unless the patient has started a new one since). The signed copy stays exactly as it was signed; each amendment is added after it, and the chart copy in the Notes feed shows the same.

Print¶

Print opens the signed note on its own page under the clinic's name and the patient's name and date of birth, with the amendments, and prints it.

The summary to the patient¶

The draft also writes an after-visit summary addressed to the patient in plain words (under 150 words, in the patient's language): what was found, what to do at home with the dosage, what to watch for, when the next visit is. It goes out with the signature when Send the summary when I sign is on in the sign sheet; otherwise, after signing, Send summary to patient shows it for editing and posts it as a message in the patient's thread with their care team. It goes once, with the usual notification of a new message, and only while the patient is still in the therapist's care; the note then says "Sent on …".

The Documentation worklist¶

The dashboard's Documentation tab (with the flag; the dashboard's existing Notes tab keeps the AI notes) is the therapist's own worklist, with counts: To sign (drafts, oldest first; one older than the clinic's limit carries a chip), Visits to resolve (where the clinic schedules here: booked visits of the last two weeks that were never checked in or closed, two hours after their end; Came completes the visit and opens its note, No-show marks it), Visits without a note (the last two weeks; Start note on each), Due (the plans with something due: a progress note due or overdue, a certification expiring or expired, a patient past the yearly threshold, an episode that lapsed; a row opens the patient's Documentation tab) and Signed recently (the last 30 days). New note at the top starts a note for any of the therapist's patients. Where the clinic also schedules here, Due lists an active plan of care with no visit booked ("Active plan, nothing booked"); a row with only that opens the patient's Appointments to book the next visit.

The plan of care on the calendar¶

Where the clinic schedules here and the Medicare rules apply to the patient, the calendar knows what the plan asks for. An appointment says Progress note due at this visit on the coming visit where the progress note falls (counting the visits already booked before it), and After the plan's certification: re-certify on any visit after the certified period; the app's list of a patient's appointments shows the same. Booking a visit after the certified period warns before booking ("3 of these visits are after the plan of care's certification ends on Nov 30").

Signing a discharge summary offers to cancel the visits still booked for the patient: the ones the therapist may change (all of them for a clinic administrator), with the patient told unless switched off, and a word about any that are a colleague's. Keep them leaves the calendar as it is.

In the app¶

The app captures during the visit, signs what is ready, and reads afterwards; the full editor stays on the web. The dashboard's Today card and the This week card under it open each visit's own sheet: the intake's summary and flags, the brief before the visit, Start visit (checked in, started, the note opened with the timer running), running late, a move, a cancellation, the next visit once it is done, and Open patient. A patient's Notes quick action (with the flag, not for a sample patient) shows the plan of care in one card (the case, the terms, the certification, the Medicare line), the referral and the documents (photograph the script and confirm what AI read, photograph a report or the insurance card, open what is there), the goals, the notes with their status, the visits without a note with Start note, and New note (an evaluation from the app takes the patient's newest case; the case is picked or changed on the web). The therapist's credentials are set under Profile. A signed note opens read-only. A draft opens the capture screen: a visit timer (Start and Stop set the visit's times and minutes), the pain row, Quick notes typed or dictated with the keyboard's microphone (saved as you go), the lab's measurements that will be offered in the note, Draft with AI (the drafted sections read-only below it, the red flags on top, the "Drafted by AI from …" line; where the clinic has it on, the draft writes itself when the timer stops and the screen says so meanwhile), and the signature: Sign the note when nothing is in the way (the attestation, the name it is signed with, the summary switch), or what still blocks it with Open in the web app. A signed note's screen offers the next visit. A push about a note opens it; one about a plan opens the patient's notes.

For the clinic¶

The Documentation tab¶

A clinic administrator opens Clinic › Documentation (with the flag): the unsigned and late notes, the notes signed in the last 7 and 30 days, and how many signed notes wait to be billed; By therapist (unsigned, late, signed in 30 days); Due (patient, therapist, what is due in words, certified through); the Notes list filtered by Drafts, Late or Signed and by therapist, in pages; and the Settings.

Settings¶

Note due (48 hours by default): a draft older than this is late on every list and reminds its author once.
Progress note every N visits (10).
Certification days (90): the period an evaluation asks the physician to certify.
Medicare rules for: Medicare patients (the default: patients whose primary insurance in the claims portal is Medicare), everyone, or nobody.
KX threshold: the year's amount can be overridden in dollars.
Timed units: Medicare's cumulative rule (the default) or the AMA's per-code rule.
Questionnaires: send the questionnaire that fits the patient with the intake, and before a progress report (both on by default).
Write the draft when a visit ends (on by default): the draft is written by itself when the app's timer stops, the visit is marked completed, or a note is opened for a visit already completed; off, the therapist presses Draft with AI.

The fee schedule¶

Claims › Setup › Visit fee schedule (with the flag; a clinic without clinical documentation sees Setup as before) lists every code of the catalog by group with the clinic's charge. Until the clinic edits a code it shows a placeholder, roughly one and a half times the 2026 Medicare national rate, marked as such; Save fees keeps the clinic's own. The fees give the charge shown on the note, the amount on the claim's lines and the clinic's count against the yearly threshold. A code the schedule does not know charges nothing and To bill says so ("Set the fee for 97139 in Setup") until it is set.

What To bill shows¶

Where the clinic bills, a signed note with services is a record in Claims › To bill like an RTM period, in the patient's group: "Visit note · Treatment note · Oct 14 · 97110 ×2, 97140 ×1 · signed by Anna Petrova · $145". Ticking it and Create claims work as before. On the claim, each line of the note is a line with the note's date of service, the fee times the units the minutes allowed, the note's modifiers (and KX when the patient was past the yearly threshold on that visit's day), and the note's diagnoses pointed at as on the note; the claim's diagnoses are the notes' (the primary first) and then the patient's on file. A claim names one treating therapist and one place, so visit notes signed by different therapists, or held in different places, go on claims of their own when they are ticked together: each claim's rendering therapist is its notes' signer, and a claim made of visit notes alone is placed where the visits were held (the office, the patient's home, or telehealth for a video or phone visit). The lines of a video visit get modifier 95. A line opened on the claim reads "From the visit note of Oct 14 (treatment note, 33 min)", with a link to the note for a therapist.

The claim's checks read the note too: the note must be signed, the units must match what the note's minutes allow and the date the note's date, a telehealth place of service wants modifier 95, an NCCI pair on one day (97140 with 97530, or 97110 with the group code, and the like) wants 59 or XU, KX past the threshold (and KX under it is pointed out), a progress note overdue, a plan not certified yet, a certification ended, a visit outside the certified period, an episode that lapsed, the same code on the same day on another claim, and a second evaluation within 60 days. Once the claim is live, the note says "On claim #12" and cannot be voided.

The Medicare rules¶

The rules apply to patients whose primary insurance is Medicare (as recorded in the claims portal), or to everyone or nobody as the clinic sets. They are shown on the note's Medicare card ("Visit 5 of the plan"), on the chart, in the worklist's Due, on the clinic's Documentation tab and in the claim's checks.

A progress note at least every tenth visit. The first reporting period starts on the day of the evaluation, which counts as its first visit; a later one starts with the visit after the progress note (or re-evaluation) that ended the one before. So after an evaluation the progress note is due on the tenth visit counting the evaluation; the note says "Progress note due in 2 visits" two visits ahead, "due this visit" and "overdue", and the suggested kind becomes a progress note. When a signed note makes the next visit the tenth, the plan's therapist gets a push, once.
Certification, 90 days. The evaluation sets the period the physician is asked to certify (90 days from the evaluation by default); the plan reads Pending, Sent or Certified through a date. From 14 days before the end it reads expiring, with a push to the therapist once per period; after it, expired; a visit dated outside the certified period is flagged. The claim's checks say that Medicare pays once the plan is certified.
The yearly threshold ($2,480 in 2026). Past the KX threshold every line of a visit carries the KX modifier, judged per visit: the patient's therapy charges of that visit's calendar year up to and including that visit, plus what other providers used that year (so December visits billed in January count against December's year, and visits from before the patient crossed carry none). The count also runs after a discharge. The note says "Past the yearly threshold: KX goes on every line"; from 80 % of it the note says the patient is near it. The count is the clinic's own charges for the patient in the calendar year (the fees times the units of the signed notes) plus what other providers used this year, as recorded on the patient's billing record in Claims › Patients ("Therapy threshold used elsewhere this year" and the date it was read from the Medicare eligibility answer or heard from the patient). The amounts of 2024 ($2,370), 2025 ($2,410) and 2026 ($2,480) are known; a later year uses the latest known amount and says it is an estimate, unless the clinic sets its own.
The $3,000 medical review threshold. Past it, the note and the claim say so: claims may be picked for targeted medical review.
The 60-day lapse. An active plan with no signed note for more than 60 days has lapsed: Medicare treats the episode as ended and expects a new evaluation. It is flagged on the chart, the worklist, the clinic's Due list and the claim's checks.

For the patient¶

The patient sees the notes themselves not at all. When the therapist sends the after-visit summary, it arrives as an ordinary message in the thread with their care team, in their language: what was found, what to do at home, what to watch for, when the next visit is.

A questionnaire the therapist asks for arrives as a notification with a link that opens without signing in, and waits on the dashboard (web and app) under Questionnaires with the minutes it takes: one question per screen, answered by tapping (the Oswestry and the Neck Disability Index show each section's own statements, the others their scale), and the score goes to the therapist. An answered one shows the score; a reminder comes once if it waits three days.

Notifications¶

Who	When	Channels
The note's author	A draft older than the clinic's limit (48 hours by default): one try per note, in the clinic's daytime (a therapist who switched these notices off is not tried again)	Their preference (push and email by default)
The plan's therapist	A signed note makes the next visit the tenth since the last progress note: once per visit count	Their preference
The plan's therapist	A certified plan of care ends within 14 days (where the Medicare rules apply to the patient): once per period, in the clinic's daytime	Their preference
The patient	A questionnaire is asked of them (by the therapist, with the intake, or before a progress report), with the link that needs no sign-in; reminded once after three days	Their preference (push and email by default)
The therapist who asked (or the plan's)	The patient answered a questionnaire	Their preference

The push about a note opens the note (the capture screen in the app); the push about a plan opens the patient's notes in the app and the dashboard's Documentation tab on the web. The emails are in the clinic's language.

Where AI is involved¶

The first draft is written by OpenAI (the clinic's note model, gpt-5.4-2026-03-05 unless the server names another) from the record as text: the patient's age, cases and facts on file, the diagnoses, the plan and the goals, the intake summary (itself written by AI from the patient's answers), the last two signed notes, the sessions since the last note with their pain and exertion ratings and what the patient wrote, the lab's measurements, the outcome scores, the video visit's note, live notes and the therapist's notes (or its transcript), and what the therapist typed or dictated. The patient's name is not sent; what the therapist typed or a transcript may still carry one. The request is not stored by OpenAI (store: false), and the platform's AI log keeps the shape of the answer (how much came back), never the words.
The draft is a reading of the sources, not a diagnosis: AI only repeats the diagnoses the record already names, never invents a finding, a measurement, an exercise, a dosage or the minutes, and the therapist reviews everything before signing. The sign checks apply to a drafted note as to any other.
Everything AI wrote is said in words, on the note, in the printed copy, in the chart's Notes feed and in the app: "Drafted by AI from …". Nothing in documentation marks AI content with a sparkle.
The measurements imported from the lab are the clinic's own tests' numbers, computed, not interpreted; the outcome scores are what the therapist entered or the patient answered.
The text of a physician's report or a surgeon's protocol goes to the draft's model with the patient's name and date of birth struck out, as the rest of the record goes without a name; the referral's line names the physician, never the patient.
The referral is read from its photo or its PDF's text by OpenAI (gpt-5.5 unless the server names another, the claims portal's screenshot reader's model), not stored by OpenAI (store: false); the AI log keeps counts, never the words. It reads only what is printed, never guesses a field and never invents a diagnosis code; every field is confirmed by the therapist, and the chart says the referral was read by AI and who confirmed it.
For a patient without a referral, the diagnoses the draft proposes are AI's reading of the findings and are marked as such; the therapist puts them on the note or not. AI's proposed goals, terms and rehabilitation potential are proposals in the same way.

Not in this version¶

A co-signature: a note written by a physical therapist assistant or a student is signed by its author; the CQ modifier is on the line, but no second signature is asked for.
The physician's electronic signature of the plan of care: the certification is recorded by hand as sent and certified.
Smart phrases (dot phrases) inside a section; templates fill whole notes.
Functional tests (the Y-balance, hop tests, the star excursion) as instruments of their own, and exercise variations with the reps and time read from the video.
Reading what other providers used of the yearly threshold from the Medicare eligibility answer automatically (today it is typed in from it).
The full editor and the signature in the app: the app captures during the visit; the review and the signature are on the web. A PDF is added on the web; the app photographs.

See internal/clinical-documentation.md for the data model, the services, the draft's context and rules, the compliance engine, the claims bridge, the endpoints and the tests.