When You’ll Use This Article
Use this article when you need to:
Document a therapy session
Complete scheduled patient visits
Record treatment minutes or non-billable tasks
Resolve missing documentation alerts
Sign or correct a Daily Note
Role Applicability
Therapists: Create and submit Daily Notes
Assistants: Create Daily Notes when permitted
DORs: Monitor documentation and alerts
Overview
Daily Notes capture services delivered for all billable services, are always tied to a Date of Service and impact:
Billing
Productivity reporting
Closeout alerts
Compliance workflows
When Daily Notes Appear
A Daily Note is expected when:
A therapy task is scheduled in Therapist Scheduling
An Evaluation occurs
Treatment minutes are delivered
If a session is scheduled but not documented, the visit may trigger:
Documentation alerts
Missed billing visibility
Month-end closeout errors
How to Start a Daily Note
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 & Active Payer: 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.
Step 1 — Open Your Patient List
Daily Notes can be started from:
My Day Dashboard → Today’s Patients, OR
Daily Notes & Billing Tab via the 'Todays Patients' list or 'Other Patients' if they are not on your schedule
Select the patient for the correct Date of Service.
Step 2 — Select the Correct Date
Confirm:
Patient name
Discipline
Date of Service*
*Daily Notes cannot be reassigned across dates once submitted.
Step 3 — Enter Treatment Details
Complete required fields:
Treatment activities
Skilled interventions
Patient response
Minutes for each billed code
Notes
If a billing code appears, minutes must be entered. Entering 0 minutes may trigger billing or closeout alerts.
If a patient does NOT have a active certification you will be unable to start the note and need to add an active payer in the patients payer tab OR an evaluation/recertification may need to be created.
IMPORTANT: Be sure to mark off if the note is a Missed Visit or Telehealth, as this will effect the fields for you to fill out and submit.
Autosave Behavior
Daily Notes automatically save while documenting.
You may safely navigate away if needed.
To resume:
Return to the Daily Notes and Billing page
Reopen Patients Daily Note for the specified date
Continue documentation
A note becomes permanent only after selecting Submit.
Submitting the Daily Note
After completing documentation:
Click Submit
The note moves to Signature Pending
The note becomes part of reporting and billing workflows
Unsubmitted notes do not count as completed documentation.
Signing Daily Notes
Daily Notes require therapist signature.
You may sign:
Directly within the patient record, OR
From My Signature Pending, OR
Within the Daily Notes and Billing tab directly after submitting
Bulk Signature
Multiple notes may be signed at once when available via 'My Dashboard'.
Correcting a Daily Note
If a Daily Note contains errors:
Locate the note in the Episode of Care
Click the three dots menu
Select Undo Signature (if signed)
Edit the document
Resubmit and sign
Permissions determine who may edit documentation.
Common Questions
Q: Why can’t I start my Daily Note?
A: Confirm the Date of Service falls within an active payer and certification period.
Q: Why does my Daily Note show as overdue?
A: A scheduled session exists without a submitted note or missed visit entry. Often a note was completed on the incorrect date resulting in the system flagging missing billing.
Q: Can I complete a Daily Note for a past date?
A: Yes, be sure you have the correct date selected and you can complete the note for a date in the past. We recommend completing the note the day of to avoid date mix ups and ensure accuracy.
Q: Why do billing alerts appear after submission? (DOR View)
A: Alerts commonly occur when:
Minutes are missing from the Note
Required codes were not billed
Codes contain 0 minutes
Q: Why are codes missing from the Daily Note that I need to bill for?
A: Ensure those codes appear on the latest evaluation or progress note. They should appear at the top of the patients EOC for that given discipline.
Add missing code to latest evaluation or progress note and the codes should appear on the Daily Note when editing.
If all codes appear on the latest evaluation or progress note document, please reach out to our support team to manually add the code.
Important Rules
Daily Notes are date-specific records
Minutes must match delivered services
Billing codes require minutes
Notes outside payer coverage cannot be submitted
Missing notes trigger compliance alerts
Troubleshooting
If a Daily Note cannot be completed:
Refresh the browser
Confirm patient certification dates
Confirm payer coverage dates
Verify scheduling status
If the issue persists, submit a ticket through the chat widget.
If you need any further support, please contact your Customer Success Representative. We’re happy to help!