Rehab and therapy EMR software, built around the plan of care

Physical therapy documentation centers on the initial evaluation, a plan of care with measurable goals, daily notes and progress reports. For US Medicare patients, the system tracks physician or NPP certification of the plan within 30 days of the first treatment, recertification at least every 90 days, and a progress report at least once every 10 treatment days. Flowsheets log minutes for timed codes such as CPT 97110 and 97140 so the 8-minute rule can calculate units, add the GP modifier, and flag CQ when a physical therapist assistant furnished part of the service.

Plan of care · 8-minute rule · GP and CQ modifiers · Progress reports

Occupational therapy notes focus on activities of daily living, fine motor skills, cognition and the home or work environment. A custom EMR can hold ADL and IADL assessments, splint and orthosis fabrication records, adaptive equipment recommendations and home safety evaluations next to the plan of care. Claims carry the GO modifier, plus CO when an occupational therapy assistant furnished part of a service. Under Medicare, OT has its own KX modifier threshold, separate from physical therapy and speech-language pathology combined, so the system keeps a per-patient running total by discipline and prompts staff to confirm medical necessity.

ADL and IADL assessments · GO and CO modifiers · Separate OT threshold · Home safety

Speech-language pathology practices document articulation, language, voice, fluency, cognition and swallowing, often with standardized test scores and instrumental swallow study results. Many SLPs also work in schools, where goals are written into an Individualized Education Program (IEP) and sessions are logged against the IEP schedule, or deliver teletherapy that needs video, shared materials and remote consent. Medicare claims carry the GN modifier and count toward the same KX threshold as physical therapy. A useful EMR keeps clinic, school and telepractice caseloads in one record while applying the documentation rules of each setting.

GN modifier · IEP goals · Teletherapy · Swallow studies

Chiropractic visits are short and frequent, so SOAP notes need templates a clinician can finish in the treatment room. US Medicare covers chiropractors only for manual manipulation of the spine to correct a subluxation, billed with CPT 98940 to 98942. A subluxation shown by physical exam needs two of the four PART findings (pain, asymmetry, range-of-motion abnormality, tissue or tone change), one of them asymmetry or range of motion. The AT modifier marks active or corrective treatment and must not be used for maintenance care. Personal-injury and workers' compensation cases add attorney correspondence, state-specific forms and narrative reports.

SOAP notes · AT modifier · PART exam · PI and workers' comp

Sports medicine clinics combine injury care, rehabilitation and athlete performance, often for teams, schools and clubs. The record needs pre-participation physicals, injury logs by body region and mechanism, links to imaging, strength and range-of-motion testing, and graded return-to-play protocols. For concussion, CDC HEADS UP guidance describes a six-step progression in which each step typically lasts at least 24 hours and the athlete moves up only without new symptoms, under a healthcare provider's supervision. A custom system can track each step, record clearance, and share limited status updates with athletic trainers and coaches when consent allows.

Return-to-play · Concussion protocols · Injury logs · Athletic trainer access