Physical therapy notes (.pt)

Physical therapy notes: one structured note for every PT visit

Type .pt in a visit note to add the Physical Therapy block: one structured note for an initial evaluation, a daily note, a progress report, a re-evaluation or a discharge summary. It has seven sections — Subjective, Objective, Treatment, Assessment, Goals, Plan and Time — and it starts from the patient’s last PT visit, so most daily notes come down to confirming what you did today and recording what changed.

1. Check that it is on. Physical therapy notes are on by default for every Hero practice. A practice administrator, or someone allowed to manage additional features, can switch Physical therapy off (or back on) in Admin → Additional Features and press Save Changes. Turning it off removes .pt from the dot-phrase list and the block’s microphone; PT notes already written stay readable.
2. Add the block. Type .pt in the visit note and choose Physical Therapy from the list.
3. Say what you are documenting. The block asks “What are you documenting?” Press E for Initial evaluation, D for Daily note, P for Progress report, R for Re-evaluation or X for Discharge summary, or click one. Everything else adapts to the note type. When the patient had a PT visit in the last 90 days, the block fills in from it and opens as a Daily note, or as a Progress report when this is the 10th treatment day since the last report (Starts from the last visit). You can change the note type on the note-type bar at any time.
4. Work through the sections. Use the mouse, the keyboard (Keyboard reference) or your voice (Dictation), then sign the visit as usual.

A field the note type does not usually need stays out of the way; the button at the bottom of a section (for example Show 3 more fields) brings it back, and a field that already holds a value always shows (under Also recorded).

Every note starts from the last PT visit

When you add .pt and the patient had a PT visit in the last 90 days, the block fills in from that visit on its own. A notice says what came over, for example “Started from Oct 14 · Daily note · Visit 7: goals, plan of care, precautions, last measures, and the exercise program to confirm as done today.” The visit number goes up by one, and the progress-report count carries on from the last report.

1. Confirm the program you actually did. Last visit’s exercises sit dimmed at the top of Treatment under Planned from last visit — confirm what was done today. Planned rows are not printed or counted until you confirm them: click Done today on a row, change any of its cells (a new load or more reps confirms it), or confirm them all with Confirm all performed (Alt+Enter, ⌥+Enter on a Mac). Dictation confirms the exercises you say you did.
2. Re-test what you measure. Each range-of-motion and strength row shows last visit’s value beside today’s cell; type today’s value and the change appears beside it.
3. Undo if you wanted a clean start. Undo on the notice puts the block back exactly as it was. It is offered only until you change something, so it can never erase work done afterwards.

Copying a whole earlier note with the note writer’s Copy forward applies the same rules to a Physical Therapy block inside it: the program arrives as planned rows and time is never copied.

The exercise flowsheet and programs from earlier visits

The Treatment section holds the exercise flowsheet: one row per exercise, activity, manual technique or modality, grouped by category (therapeutic exercise, neuromuscular re-education, therapeutic activities, gait training, manual therapy, modalities, self-care, aquatic therapy), with sets × reps, load, time, side, a progressed mark and cues. Below it you record the skilled care you provided, patient education, the response to treatment and any home-program update.

1. Add an exercise by name. Click + Exercise (or press /) and start typing. The suggestions list this patient’s own exercises first, with their last dose (for example Monster walks · 2×20 ft, red band · Last Oct 14), then the exercise library. Picking a suggestion copies its dose; anything you type that is not in the library is added as a new exercise.
2. Copy programs from earlier visits. From earlier visits lists the patient’s last 8 PT visits (date, note type and visit number). Open a visit to see its program, then tick exercises and press Add selected, or press Add all for the whole visit. They arrive as planned rows, exactly like carry-forward, so confirm each one once it is done today. An exercise already in today’s program is shown as (in today’s program) and is not added twice.
3. Record the dose. Type in the cells; Enter moves along the row and adds a new row from the last cell. The side cell takes L, R or B (both).

Range of motion, strength, special tests and outcome measures

The Objective section holds four tables beside a body map, then your observations (gait, assistive device, transfers, balance, posture, palpation, neurological screen, edema and other findings).

Add a row from each table’s picker (Add motion…, Add muscle group…, Add test…, + Measure…), or press / and type any motion, muscle, test or measure. On a Daily note the tables show only the rows that hold values.

Goals linked to measurements, with target dates

The Goals section lists Short-term goals and Long-term goals. Add one with + STG or + LTG and write it as you normally would (“Patient will …”). Each goal has a status: Met, Progressing, Partially met, Not met, Discontinued or Deferred.

1. Link the goal to a measurement. Link a measure… lets you pick a range-of-motion or strength row and side, an outcome measure, or a pain rating from the same note, then type the target: for example knee flexion right at least 120°, or Oswestry at most 20%. In the target, > means at least and < means at most. The baseline is taken when you link it.
2. Set a target date. Type 4w or 10d (counted from the visit’s date of service), a date such as 11/19, or pick 2 wk, 4 wk, 6 wk or 8 wk. The goal then reads, for example, Nov 19, 2026 · in 4 weeks.
3. Let today’s numbers speak. A linked goal shows today’s value beside its baseline (today 115° · baseline 95°), read straight from this note’s measurements, so you never re-type a number. When today’s value reaches the target, the goal offers Target reached — mark Met; Hero never changes a status on its own. A goal marked met whose value falls short says Marked met; today is short of the target.

Time: minutes per service, and charges built for you

The Time section records what Medicare asks a therapy note to show: what you did and for how long, by the names you use — Therapeutic exercise, Manual therapy, Neuromuscular re-education, Gait training, Therapeutic activities, modalities and the rest — and the total treatment time. There are no codes, units, unit rule or modifiers in the note: completing the visit turns your minutes into charge lines.

1. Add today’s services. From today’s interventions suggests the services behind the exercises you confirmed on Treatment: click one to add it. + Service… adds any other timed service. On a note that started from the last visit, Last visit: … with Add the same services adds last visit’s services with empty minutes. Untimed services (hot/cold packs, mechanical traction, unattended electrical stimulation, dry needling and others) are checkmarks under Untimed services.
2. Type the minutes. Each timed service has a minutes box: ↑/↓ change it by 1 (Shift by 5) and Enter moves to the next service. Dictation fills a minute value only when you say it for that service (“twenty-three minutes ther ex, fifteen minutes manual”).
3. Check the total treatment time. The box shows the sum of your services as a placeholder (53 (sum of services)); leave it to use the sum, or type the actual total when it differs. The footer shows, for example, 38 timed min · 53 min total, and the checklist asks for minutes on every timed service and for the total treatment time.
4. Read the unit hint if you like. ≈ 3 units by the 8-minute rule is for reference only; click it to see how your minutes count (for example 38 timed min ≈ 3 units (2 × 15 min + 8 min: 8 or more counts one more)). The billed units are set when the visit is completed.
5. On an evaluation, rate the evaluation complexity. The Evaluation complexity card takes the four components (history, examination, clinical presentation, clinical decision making) and shows the complexity they support. Completing the visit adds the matching evaluation code; a re-evaluation gets the re-evaluation code.

What completing the visit builds

When you complete the visit, Hero turns the Physical Therapy block into charge lines in Charge Capture, the visit’s Charges section, so you never type the codes twice:

• One line per service, with its code. Timed services get units by the 8-minute rule; untimed services get one unit.
• The unit rule follows the payer. Medicare and Medicare Advantage always use the CMS 8-minute rule (units from the total timed minutes). Other payers follow your practice setting: the CMS rule by default, or the per-code rule (each timed service needs 8 minutes of its own).
• Therapy modifiers for who wrote the note: GP on physical therapy lines, plus CQ when the note was written by a physical therapist assistant. KX is never added for you; that stays the biller’s decision.
• Evaluation codes come from the evaluation complexity on an initial evaluation, and the re-evaluation code from a re-evaluation.
• It keeps up with your edits. Each Save updates the lines as your minutes change; a line you removed is not added back, and modifiers you added stay.
• Notes above the codes tell you when something needs a person, for example when the evaluation complexity is incomplete (no evaluation code is added), when Hero cannot tell whether the note’s author is a physical therapist assistant (add CQ where an assistant provided the service), or when the timed services total less than 8 minutes.

Review the codes, units and modifiers in Charges before you sign, as you would for any visit; the coding decision stays yours.

The documentation checklist for each note type

The footer’s Documentation checklist counts the elements this note type needs (for example Documentation checklist 7/9). Click it to see the list: missing items come first, and Go to field opens the right section with the field focused. It lists “Elements Medicare and most payers expect — not a coverage determination”: it is guidance only and never stops you from saving or signing.

Dictate into the block, or record the whole visit

The block fills from your voice two ways. Values filled by dictation carry a small sparkle, and a section tab shows a dot when it holds them. Anything you typed or chose yourself is kept: dictation fills around it.

1. Targeted: speak to the block. Click the microphone in the block’s title bar, or press D while a section tab has focus, and say what you measured or did: “knee flexion right 115, MMT quads 4 minus, Lachman negative”, “clamshells three by fifteen, green band, verbal cues”, “short-term goal one met”. Each tab’s Try: line shows an example for that section. Corrections work the same way (“progressed clamshells to blue band”).
2. Ambient: record the whole visit. Add .pt to the note and record the visit with the round microphone in the note header, as you would for any visit (Dictation & transcripts). When the note is written, the block fills itself from the conversation alongside the rest of the note: pain, measurements, the exercises you did, responses, goal statuses and the plan.
3. Review before you sign. Minutes are kept only when they are said for a service (“twenty-three minutes of therapeutic exercise, fifteen manual”); Hero never estimates them. A planned exercise the conversation shows you skipped stays planned for you to confirm or remove. Check every dictated value, then confirm the rest of the program.

The note text you sign and print

Press Note text (or T on the section tabs) to see exactly the text this block adds to the note; Show interactive goes back. The text starts with one line naming the note type and visit (Daily note · Visit 8 of 12), then one heading per section with its lines: range of motion with previous values, strength grades, special tests, outcome measures with baseline, change and MCID met, the exercises grouped by category with their doses, each goal with its status and its linked measure (Knee flexion R ≥ 120°: today 115°, baseline 95°), the plan, and the treatment time.

The time prints under Treatment time, one service per line, then the totals, for example: Therapeutic exercise: 23 min / Manual therapy: 15 min / Hot/cold packs (untimed) / Total timed minutes: 38; total treatment time: 53 min. Codes, units and modifiers are not part of the note; they live in Charge Capture.

• Planned exercises that were not confirmed are left out, so the note documents only care given today.
• Empty sections are left out; dates print as year-month-day.
• A signed note opens in note text; this is the text in the printed note and in exports.

Keyboard reference

Every action is also a button, and the question-mark key (?) inside the block lists every key. Letter keys work when the cursor is not in a text field; Alt keys and Esc work anywhere in the block. On a Mac, Alt is ⌥ Option and Ctrl is ⌘ Command.

Questions and troubleshooting