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Write a treatment

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RehabAlpha is still under active development. It is not yet HIPAA compliant and should only be used with dummy data.

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. Enter Minutes for each service, including untimed services. Enter 0 or remove a service row if that service was not provided.
  5. Add patient response, skilled rationale, and any changes to the plan.
  6. Save the treatment.

Select Resolution before signing. You can save a draft without a resolution or with blank minutes. After the treatment starts, this includes a treatment marked Completed or Completed - Partial Session. Blank minutes mean the duration still needs to be documented; they do not mean zero.

Check the treatment date and start time​

Before saving, check Treatment date, Start time, and Service location. Timing is checked in the treatment's time zone, which follows the selected service location or the case when no service location is selected.

You cannot save these resolutions before the treatment date or, when a start time is entered, before that time arrives:

  • Completed
  • Completed - Partial Session
  • Patient No-Show
  • Unable to Complete - Acute Medical Event

You also cannot save more than 0 minutes in any service row, Co-treatment, or Concurrent treatment before the treatment starts, regardless of the resolution. You can select planned CPT codes and leave minutes blank or enter 0.

You can document cancellations, Patient Refused Treatment, Not Medically Appropriate at This Time, and Transferred/Discharged from Facility in advance. If a medical event prevents an upcoming visit, select the appropriate cancellation, such as Cancelled - Medical Decline or Cancelled - Hospitalization.

For a treatment dated today with no Start time, these timing restrictions allow saving outcomes and minutes. Other save requirements still apply. When a start time is entered, saving becomes available as soon as it arrives; you do not need to wait for the estimated duration to pass. If a start time does not exist because of a daylight-saving change, choose a valid time.

Review the field messages and Signature eligibility checklist if saving is blocked. Timing requirements are marked Required to save and sign. Your entered values are preserved so you can correct the date, time, resolution, or minutes.

Future-dated treatments cannot be signed, including advance cancellations. See Request and track signatures for the signing requirements.

Complete services before signing​

In Services or interventions provided today, select a CPT code and enter whole-number Minutes from 0 to 1,440 for every service row you keep. If Co-treatment or Concurrent treatment is enabled, enter its minutes too, or remove that section. A blank means unfinished documentation. Enter 0 only when the service was not provided.

The services must match the treatment resolution:

  • Completed and Completed - Partial Session require at least one treatment CPT code with more than 0 minutes.
  • Unable to Complete - Acute Medical Event allows services actually provided before the event, or no services if none were provided.
  • For every other resolution, including cancellations, no-shows, and refusals, service rows and any co-treatment or concurrent-treatment section must have 0 minutes or be removed.

Selecting a resolution that indicates no services were provided disables Add service item, applying suggested services, and enabling additional co-treatment or concurrent-treatment sections. An empty service section explains why these controls are unavailable.

Changing Resolution preserves existing service rows, minutes, and enabled sections. You can edit or remove them, including rows or sections with blank or zero minutes, and continue documenting other clinical fields. If care was delivered, correct the resolution to reflect what happened.

When services were provided, complete these details as applicable:

  • For a group service with more than 0 minutes, enter Number of patients, including everyone in the group. The count must be at least 2.
  • For co-treatment with more than 0 minutes, select at least one discipline besides the case's discipline. Co-treatment minutes cannot exceed the total service minutes.
  • Concurrent-treatment minutes cannot exceed the total minutes for services that are not group services.

Co-treatment and concurrent-treatment minutes are already included in service minutes and do not add to the total. Notes within this section are optional; other required clinical fields still apply.

Untimed services still need their actual minutes documented. Recording a longer duration does not turn an untimed service into a timed billing code. A service shorter than eight minutes can be documented and signed; billing units are determined separately.

These service-completeness requirements apply before signing, requesting a signature, preparing a PDF for signature, or recording a signature. You can still save unfinished documentation when the treatment timing rules above are met, even if the services do not yet match the resolution, and download a draft PDF. Draft PDFs identify missing minutes separately from zero and show the service minutes recorded so far. Schedule and report totals may also be incomplete while documentation is unsigned.

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.