An intelligent EMR for the year 2026, not 2006.

Built for Physical, Occupational, and Speech Therapists.

Cash/Insurance/Hybrid. Outpatient/Mobile.

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Intelligent Clinic OS

Patient note

Draft

Initial Evaluation

Avery Morgan

Right TKA · Visit 1

PT
Voice ready

Typed note

autosaved

2 weeks s/p R TKA. Pain 4/10 at rest, 6/10 stairs.

Flexion 92 degrees, extension -4 degrees. Quad lag with SLR.

Started heel slides, quad sets, gait training.

ReferralIntakeMeasures

Documentation

Write less. Sign better notes.

Start with brief clinical sentences and objective measures. Intelligent Assist uses referral and intake context to draft a defensible evaluation in seconds.

Before Intelligent Assist

Clinician starts with brief sentences

2 weeks s/p R TKA. Pain 4/10 rest, 6/10 stairs. Flexion 92, extension -4. Quad lag SLR. TUG 16.8 sec with cane. Started heel slides, quad sets, gait training. Needs skilled PT 2x/week.

Referral context

Post-op TKA protocol and surgeon restrictions attached

Patient intake

Difficulty with stairs, sleeping, and community walking

Objective measurements includedReferral + intake used

After Intelligent Assist

Initial evaluation drafted in seconds

Completed evaluation

Initial Evaluation - Avery Morgan

Diagnosis: s/p right total knee arthroplasty. Referring physician protocol and patient intake were reviewed before drafting.

Medical necessity statement

Patient requires skilled physical therapy after right total knee arthroplasty due to restricted knee range of motion, quadriceps inhibition, antalgic gait with assistive device use, stair pain, sleep disruption, and elevated fall risk demonstrated by TUG of 16.8 seconds. Skilled intervention is necessary to restore safe transfers, gait mechanics, stair negotiation, and community ambulation while following surgeon precautions.

Objective measurement chart

Pain4/10 rest, 6/10 stairs
Right knee flexion92 degrees
Right knee extension-4 degrees
Quadriceps controlLag with straight leg raise
TUG16.8 sec with cane

Functional status chart

GaitAntalgic with cane
StairsPain-limited step-to pattern
TransfersRequires UE support
SleepInterrupted by knee pain
Community walkingLimited by pain and endurance

Assessment

Avery presents two weeks post right TKA with expected post-operative mobility deficits compounded by measurable ROM loss, quad activation deficits, gait asymmetry, and impaired functional tolerance. Referral and intake context support a supervised progression that emphasizes swelling management, safe ROM restoration, neuromuscular re-education of the quadriceps, gait normalization, and gradual return to stairs and community mobility. Prognosis is good with consistent skilled PT and adherence to the home program.

Goals

TimeframeGoal
2 weeksImprove knee extension to 0 degrees to support terminal stance during gait.
4 weeksImprove knee flexion to 115 degrees for transfers, stairs, and car entry.
4 weeksPerform straight leg raise without quad lag to support safe ambulation.
6 weeksReduce TUG to under 12 seconds without loss of balance.
8 weeksAscend and descend one flight of stairs with reciprocal pattern and pain no greater than 2/10.

Activity log and CPT justification

CPTCompleted activitySkilled justification
97110Heel slides, quad sets, straight leg raisesTherapeutic exercise is justified by ROM loss and quad lag requiring skilled dosage, cueing, and progression.
97116Cane sequencing and stance control drillsGait training is justified by antalgic pattern, reduced terminal knee extension, and fall risk during ambulation.
97530Sit-to-stand and stair simulationTherapeutic activity is justified by functional limitations in transfers, stairs, and community mobility.

Plan

Treat 2x/week for 8 weeks with therapeutic exercise, gait training, therapeutic activity, manual techniques as indicated, progressive HEP, and ongoing reassessment of pain, ROM, quad control, gait safety, and functional tolerance. Update the referring physician after objective improvement milestones or sooner if symptoms worsen.

Defensible documentationCompleted in secondsCPT codes justified

Built into documentation

Intelligent Assist does the clinical assembly

Uses referral and patient intake context before drafting
Turns brief objective measurements into a defensible evaluation
Highlights medical necessity and skilled need
Justifies CPT codes for the exercises completed
Finishes the first draft in seconds, not minutes

Billing

Claims are organized before they become problems.

See payer, patient, service date, CPT codes, units, charges, and status in one clean queue.

Insurance claims

Billing

Clinic viewSample data
PatientPayerDOSCPT / UnitsChargeStatus
Linda TorresMedicare Part B06/18/202697161, 97110 x2, 97116$412.00Submitted
Robert KingBCBS Texas06/17/202697110 x2, 97140$286.00Paid
Noah PatelUnitedHealthcare06/19/202697530 x2, 97112$318.00Accepted
Maya RiveraAetna06/19/202697110, 97530$244.00Submitted
Tara NguyenCash Pay06/19/2026Cash PT visit$120.00Recorded

Front Desk

Calls and faxes do not disappear into side tools.

Intelligent Clinic OS keeps new patient leads, callback tasks, fax matching, and follow-up work in the same clinic system.

Front Desk

Receptionist logs and leads

Marcus Hill

(512) 555-0148 · Medicare

Low back pain after lifting

NewCall back today

Jenna Price

(512) 555-0192 · BCBS

Post-op ACL referral

PrioritySchedule eval

Caleb Moss

(512) 555-0171 · Cash pay

Running injury consult

ContactedSend intake

Inbound and outbound documents

Fax Center

Inbound

Signed POC - Linda Torres

Dr. Patel Orthopedics

MatchedAttach to chart
Outbound

Initial Eval - Linda Torres

Austin Ortho Group

SentView
Inbound

MRI report - Robert King

Central Imaging

Needs matchReview
Outbound

Robert King notes

Medicare audit packet

FailedResend

Simple pricing

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