Document a visit with AI or a therapy template

Planetrehab treatment documentation lets a therapist chart a visit with AI or start from a therapy template. Templates cover the kinds of notes PT and OT clinics write every day. The treating therapist is still responsible for the final documentation.

Open the visit

Start from the schedule, not from a blank note. Opening the visit pulls the patient, the therapist, the location, and the time into the chart so billing later matches the appointment that actually happened. If the visit type is wrong — for example an evaluation was scheduled as a follow-up — fix it before you write, because the template and the codes depend on it.

Previous notes, the plan of care, and diagnoses already stored for the patient are available while you chart. You should not retype that history when it is already on the record.

Draft with AI

AI documentation can locate details already stored for the patient and help produce the note. Use it when the visit followed the plan and you want a first draft of subjective comments, what was done, and the response. Read every sentence. Change anything that overstates progress, names the wrong side, or lists a treatment you did not provide.

1. Open the patient’s visit.
2. Choose AI documentation and let the draft load.
3. Compare the draft with what you actually did in the session.
4. Edit objective findings, treatment, and the plan before you sign.

Start from a therapy template

Templates are better when the clinic wants the same headings on every daily note, progress note, or discharge. Pick the template for the visit type and fill the fields the payer expects: measurements, skilled treatment, time, and the plan for the next visit. Required fields that are still empty should be finished before the note can be signed.

• Daily note for a routine follow-up visit.
• Progress note when the plan of care period needs an update.
• Evaluation or re-evaluation when the visit establishes goals.

Review and sign

Read the note as if a payer asked for it tomorrow. Objective findings should match the treatment, and the plan should say what happens next. Sign only when the note matches the visit. A signed note is what billing uses to build the claim, so an unsigned chart holds the charge.

If you need to correct a signed note, follow the clinic’s addendum steps instead of deleting the original. The addendum keeps the first version and shows what changed.