Suggested Templates

Practice Intel:

Suggested Templates

Our AI technology reads each sentence in the documentation and attempts to identify whether or not the key components of a compliant note are present. In order to assist you in understanding how to ensure all of the components are present in your documentation, we have included a template for the subjective and assessment section of each note below. This template will help you or your clinicians understand the types of information that our technology is looking for in your documentation.

These are designed to prompt the therapist to place the proper information in the note.  If the templates are not filled with the proper compliant content based on the specific patient, the Note Audit Score will still be scored low.  

The bolded information is required. The non-bolded information is not absolutely required but is best practice. 

• Initial Evaluation
  • Subjective
    • One line summary
    • Onset mechanism
    • Signs and symptoms
    • Pain scale
    • Aggravating/Alleviating Factors
    • Comorbidities
    • Prior treatments / surgeries
    • Prior imaging / studies
    • Prior Level of Function 
    • Activity Limitations
  • Assessment
    • Clinical diagnosis
    • Patient presentation
    • Rationale for skilled therapy service 
    • Prognosis/Rehab Potential
    • Other key findings, PMH to help justify the level of care and skilled necessary therapy
    • Statement of benefit
• Follow up Visit
  • Subjective
    • Response to prior treatment
    • New patient reported functional updates
    • Pain level/location/description
  • Assessment
    • Updated analysis of how the patient performed during therapy
    • Rationale for why continued skilled therapy is medically necessary
• Progress Visit
  • Subjective
    • Report on patient condition and response to prior reporting period
    • New patient reported functional updates
    • Pain level/location/description
  • Assessment
    • Progress since the last reporting period (evaluation/progress note)
    • Rationale for why continued skilled therapy is medically necessary
• Discharge Visit
  • Subjective
    • Report on patient condition and response to prior reporting period
    • Pain level/location/description
  • Assessment 
    • Progress since the last reporting period (evaluation/progress note)
    • Reason for discharge