Start a therapy case
A therapy case is the home for one discipline's episode of care, such as PT, OT, or SLP. Start a case when a patient needs skilled therapy documentation for that discipline.
Write an evaluation
Use an evaluation to document the initial clinical picture, establish medical necessity, and create the plan of care for a therapy case.
Write a treatment
Use a treatment to document a therapy service that was provided after the evaluation.
Write a progress report
Use a progress report to summarize patient progress during an active therapy case and support continued skilled care.
Write a recertification
Use a recertification when therapy needs to continue beyond the current certification period.
Write a discharge
Use a discharge to close a therapy case and summarize outcomes, remaining needs, and recommendations.
Request and track signatures
Some clinical documents need a physician, supervisor, or other authorized signer to review and sign them.