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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.

Before you start​

Gather the information your organization expects for an evaluation:

  • medical and treatment diagnoses
  • prior level of function
  • current functional limitations
  • objective measures
  • goals
  • treatment frequency and duration
  • planned CPT codes or service types

Complete the evaluation​

  1. Open the patient's therapy case.
  2. Click Evaluation.
  3. Choose the correct template if more than one is available.
  4. Complete all required fields marked with an asterisk.
  5. Add diagnoses in the correct order.
  6. Enter the treatment plan, including frequency and duration.
  7. Add planned services or CPT codes when required.
  8. Save the evaluation.

After saving​

Review the case page to confirm that the evaluation, treatment plan, and scheduled treatments look correct. If physician or supervisor signature is required, send the document for signature.