How documentation works

ArkCloud Rehab keeps one note record for all clinical narrative. What distinguishes an evaluation from a visit note is its document type, which decides its template of sections. There are six:

The sections follow the episode's care setting and discipline (and, for OT, a specialty such as hand therapy), so a PT, an OT and an SLP note of the same type differ. The full comparison is in note types compared. The plan of care exists twice on purpose: a structured treatment plan that work queues and billing read, and the signed Plan of Care note that says the same in narrative.

ArkCloud Rehab → Records and revenue → Episodes → an episode → Notes → Clinical documentation

The episode page is split into views - Overview, Notes, Evaluation, Goals & outcomes, Care team & billing and History (see Patient Home). All notes live in one Clinical documentation section on the Notes view: one New document menu, one visit picker, chips that show each note type's drafts and signed notes and jump to the latest, and one list of every note, newest first.

Structured facts are recorded on the episode, not inside the note text, so they can be compared over time. Each reaches a note only when you insert it, and you see the exact text first. Values from an earlier visit are never copied forward.

1. On the episode, choose the type in New document.
2. Choose the visit the note documents, or No specific visit (episode document). A visit note must be written against its visit for signing to update that visit's billing readiness.
3. Press Start. The template comes from the episode's setting and discipline. Nothing is prefilled with example findings.
4. Write and insert. The note saves as you type and stays a private draft until signed.
5. Press Sign, review the sign check, and confirm your identity. See review, signing and amendments.

AI never writes into a note by itself. A draft is shown beside the note and a clinician inserts each section, edits it or discards it. Notes are not generated automatically from the episode.

What the visit-note draft reads. Today's Quick Capture, any notes, assessment and plan you typed for it, your dictated summary, and services, mobility, examination findings and screening answers recorded today; the episode's goals, plan of care, precautions, diagnosis, cognition and home programme; and earlier confirmed findings, the previous signed note's assessment and plan, earlier measurements and outcome scores. Each source is labelled today, standing or earlier. Subjective and Objective may rest only on today's sources, and earlier values may appear only in the Assessment. The draft is not sent the patient's name, date of birth, MRN, address, payer or charge amounts. A sentence with a number, side or assistance level its sources do not contain is removed, and you are told why.

What the narrative draft reads (Progress Report and Discharge Summary): the reporting period, visit counts, the recorded goals and the assessment and plan of up to three earlier signed notes. It does not use outcome scores you entered yourself.

Patient AI agreement. If your clinic has installed the AI agreement form, the visit-note draft and visit recording are refused for a patient who has not signed it or who answered no. If the clinic has not installed it, nothing is gated by it.

Only the author signs; the text, their credentials and the allergies and precautions shown at that moment freeze. A blank required section does not block signing, but Sign lists it first, and a note signed that way is held from billing as "note incomplete". After signing, a note changes only by amendment with a reason, can take signed addenda, and can be locked permanently. Signing needs a discipline grant, an active staff record and a current licence, set up by an administrator under Outpatient → Clinician billing. Everything else is on review, signing and amendments.

ArkCloud does not assume a progress-report interval. An administrator sets one under Administration → Progress reports; with no policy set, nothing is ever reported as due. For Medicare, charge capture separately holds a visit more than 10 treatment days after the last signed progress report or re-evaluation. The structured plan carries a review date and, where a payer needs it, the period of the physician's sign-off of the plan; both surface in the work queue as they fall due.

Discharging an episode is separate from writing the Discharge Summary. Every open goal needs an outcome, and the person discharging needs signing authority for the discipline or the Supervisor or Admin role. Unsigned notes and a missing summary are reported but do not block discharge. A discharged episode cannot be reopened. See Discharge Summary.

• Note text is encrypted at the field level before it reaches the database.
• Templates are versioned. A note keeps the template version it was written under, so a signed note still renders with its original sections after a template changes.
• The templates and pick-lists have not been clinically validated by ArkCloud; each practice records its own review. Payer documentation rules differ, and ArkCloud documents only its own requirements.
• Clinical notes are not given document numbers.
• Signed notes are protected by the database itself: they cannot be changed except by amendment, or deleted, including by deleting the patient or episode.
• Nothing creates a charge automatically. Signing a visit note only refreshes the visit's billing readiness. A charge is created when someone with fee-management permission uses Post charge in charge capture; interventions and treatment activities in a note never create or change one.