Ensure Prerequisites are Met
Before initiating the creation of a Daily Note, therapists need to confirm that the following prerequisites have been fulfilled:
Open Episode of Care: Ensure that an Episode of Care has been opened for the patient in the system.
Completed Evaluation: Submit the evaluation relevant to the discipline involved in therapy.
CPT Codes Entry: Enter the appropriate CPT codes during the evaluation process to enable the creation of daily session notes.
Patient is Scheduled to You: Ensure your DOR has scheduled that patient to you on the correct date.
Entering Your Note
REMINDER: Be sure you have the correct date selected as you can not adjust once your note is initiated! You will have to request a deletion and re-start.
Supervisors: If your facility has a list, you’ll see a dropdown. Otherwise, enter the supervisor’s name and credentials manually.
Missed Visits: If a session is marked as missed, billing and additional notes will be hidden, and a reason must be entered before submitting.
Billing Section
Minutes & Notes
Codes will auto-populate from the Evaluation, if codes are incorrect, check your evaluation to ensure the proper codes were inputed. If issues still persists, please reach out to our support team.
NOTE: If you add minutes to a billing code, you must enter a note for that code
Understanding the Calculations
Total Treatment Time = Individual + Group + Concurrent + Eval minutes.
Individual Minutes = Total Treatment Time - Group - Concurrent - Eval minutes.
Concurrent Minutes cannot be more than Individual - Eval minutes.
Co-Treatment Minutes cannot be more than Individual + Concurrent - Eval minutes.
If Co-Treatment Minutes are entered, you must select a Co-Treatment discipline.
Additional Notes Section
Some fields are required, and others are optional, depending on facility settings.
Precautions Field
Any precautions entered will carry over to the next document, reducing repeated entries.
Finalizing Your Note
Complete all required fields and click Submit.
If anything is missing, the system will guide you to fix it before submission.
Patient not appearing? If all prerequisites are met, submit a support ticket VIA the purple chat box.
*NOTE: You should still be able to complete the note VIA the "Other Patients" list or manually typing in the patients name in the Patient list within the Daily Notes & Billing tab.
By following these steps, you can document your session quickly and correctly!