Your documentation needs to be fast, efficient, and complete. We know that because our documentation module was built by industry experts!

  • Embedded clinical decision support

  • Built in alerts, notes, and reminders

  • Quick and easy documentation guided by science

  • Compliance features at your fingertips to reduce burden

  • Electronic outcome measures to reduce paperwork

  • Fully customizable patterns, text templates, and more


Improve patient care, documentation, and communication with built-in dynamic Clinical Decision Support at point-of-care.

Use evidence-based practice patterns to assist you in examining patients and documenting the results consistent with professional standards.

Access pre-sorted measures based on evidence and clinical research and customized practice patterns that assist with efficient documentation performed at the “point of care” .


Reduce risk of punitive audits with our integrated documentation and compliance alerts, designed and constantly updated.

Utilize built in prompts and alerts throughout documentation to guide proper coding and billing practices.

Enjoy embedded alerts, prompts, reminders, and real-time recommendations to facilitate compliant documentation.

Seamlessly integrate Medicare documentation requirements for initial evaluations, treatment notes, progress reports, reevaluations, and discharge statements.

Ensure optimal compliance through codes that are both captured correctly and appropriately described based on documentation of services.


Enhance revenue capture through accurate and necessary data capture and reporting.

Manage and share clinical information in multiple report formats that provide necessary/desired information for colleagues, referring physicians, and payers.

Develop and utilize customized clinical practice patterns to create consistency and efficiency in data capture, seamlessly populating codes justified by documentation in the medical record.

Dynamically calculate Medicare therapy cap limitations and generate codes/modifiers required by payers with built-in notifications.


Embedded outcome measures make documentation simple and accurate.

Send your outcome measures electronically to the patient ahead of time through optimumMe or email.

Accurately score and easily add your collected outcome measures to your documentation.

Analyze your trends and outcome performance.