Physical Therapy Documentation Software

Structured templates for initial evaluation, progress note, re-evaluation, and discharge summary -- each configured with the clinical fields appropriate to that note type in PT, not in general medicine. The initial evaluation template captures the full intake: subjective history, mechanism of injury, prior treatment, functional limitations, objective measurements, assessment with diagnostic impression, and the treatment plan with functional goals. The progress note template surfaces the goals set at evaluation and requires a status update for each one. The subjective section captures patient-reported pain, function since last visit, and home exercise feedback in structured fields rather than a free-text paragraph. The objective section has entry fields for measurements, treatments, and exercises rather than a blank text area. Quick-copy from the previous visit's stable fields -- diagnosis, prior history, patient demographics -- with mandatory review before submission so the therapist confirms accuracy rather than accepting defaults.

An interactive body diagram for pain location, movement restriction, treatment area, and surgical site notation -- the therapist marks the relevant regions on the diagram and the annotation is stored against the visit note. Region-specific clinical fields load based on the body area selected. A lumbar note surfaces flexion, extension, lateral flexion, and rotation ROM fields, lumbar special tests, and relevant functional assessments. A shoulder note surfaces glenohumeral ROM by plane, rotator cuff strength by movement, and shoulder-specific outcome measures. A knee note surfaces flexion and extension ROM, quadriceps and hamstring strength, girth measurements, and knee-specific special tests. The region-specific field set reduces what the therapist has to navigate to complete the objective section and eliminates irrelevant fields that create noise in the note.

Range of motion is entered by joint and movement plane with the value compared automatically to the previous visit's measurement and to normative range values for the patient's age and sex. A measurement that has changed by a clinically significant amount since the last visit is flagged so the therapist sees the delta without manually comparing notes. Manual muscle testing grades are entered by muscle group with a standard grading scale. Girth and limb circumference measurements are tracked across the episode with trend display. Special test results are recorded with pass, fail, or a graded outcome depending on the test. Measurement trends for each tracked variable are displayed as charts across the full care episode so the therapist and patient can see the trajectory during the session rather than looking back through individual notes.

A structured treatment log linked to the SOAP note captures every intervention applied in the session: modalities with body region, duration, and settings; manual techniques with technique name and body region; therapeutic exercises with exercise name, sets, reps, resistance, hold duration, and patient tolerance; gait and balance training with distance, assistive device, and surfaces; and neuromuscular re-education with technique and patient response. The treatment log drives CPT code suggestion for billing -- the system reads the log entries and applies the correct timed and untimed CPT codes based on the procedures recorded and the minutes tracked. Time tracking for timed codes -- therapeutic exercise, manual therapy, neuromuscular re-education -- is calculated from the log entries using the eight-minute rule so the therapist doesn't calculate units manually and the billing module receives accurate CPT data directly from the documentation.

Each completed note is signed by the treating therapist with a date and credential stamp applied at the time of signing. Notes that require a supervising PT co-signature -- PTA notes, student notes, intern notes -- are routed automatically to the appropriate supervisor's signing queue rather than requiring the supervisor to search each therapist's note list. The co-signature queue shows the therapist name, patient name, visit date, and note type for each item awaiting review so the supervisor can work through the queue efficiently. Supervisors can open, review, and co-sign directly from the queue without navigating to individual patient records. An unsigned and incomplete note dashboard is available to practice managers showing every therapist's documentation compliance status by day -- notes not started, notes in progress, notes signed, and notes awaiting co-signature -- so documentation gaps are caught before they become compliance issues.

Standardized outcome measures -- LEFS, DASH, NDI, Oxford Shoulder Instability Score, and Patient-Specific Functional Scale -- are configured for delivery at intervals set at intake for each patient. The questionnaire is sent to the patient via the portal between visits at the scheduled time, and the completed score returns automatically to the therapist dashboard without requiring a clinic visit. Scores are displayed as trend charts alongside the patient's previous scores and the minimal clinically important difference threshold for each measure, so the therapist can see whether the change is clinically meaningful. Functional goals documented at initial evaluation are tracked at each subsequent visit with a status field indicating whether the goal is on track, achieved, or requires modification. At discharge, goals achieved are flagged and the functional outcome data is included in the discharge summary. Aggregate outcome data across the practice is available for quality reporting and service line performance review.