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Write a treatment

Use a treatment to document a therapy service that was provided after the evaluation.

Before you start​

Confirm that:

  • the patient has an active therapy case
  • the treatment is tied to the correct date
  • the treating therapist is correct
  • the planned service matches what was provided

Complete the treatment​

  1. Open the patient's therapy case or schedule.
  2. Select the treatment.
  3. Document the interventions provided.
  4. Record the service time.
  5. Add patient response, skilled rationale, and any changes to the plan.
  6. Save the treatment.

Good documentation habits​

  • Match the note to what actually happened during the visit.
  • Explain why the service required skilled therapy.
  • Update the plan when patient status or tolerance changes.
  • Make sure the service log reflects the minutes provided.