ArkCloud Rehab
Initial Evaluation
The episode's first formal evaluation: why the patient was referred, what limits them, your clinical assessment, measurable goals and the plan of care. One per episode, written by you, with recorded findings brought in only when you choose.
Written for: Physical therapists · Occupational therapists · Speech-language pathologists
When you use it
At the first visit of a new episode of care. An episode holds one Initial Evaluation; once it exists, the New document menu no longer offers another, and a correction is made by amending the existing note. A later formal evaluation of the same episode is a Re-evaluation.
Before you start: the patient needs an episode with its discipline and care setting, and the visit should have been started from the schedule so you can pick it.
Start, complete and sign
ArkCloud Rehab → Records and revenue → Episodes → the episode → Notes → Clinical documentation
- In New document, choose Initial Evaluation. Before an episode has one, it is first in the list.
- Choose the visit the evaluation was done at, then press Start.
- Record what you assess where it belongs on the episode: the body map and guided questions, mobility and assistance, and any outcome scores your clinic has approved. Confirm the findings you stand behind.
- Write each section. Use Confirmed findings from the body map and mobility to append confirmed findings into the matching sections, Use in an evaluation on the patient's outside records to bring in reviewed entries, and Add to note on an outcome score to add a score line. You see the exact text before it goes in.
- The note saves as you type. Leave a section blank if you did not assess it.
- Press Sign. Review anything the sign check lists, fix it or press Sign anyway, and confirm your identity if asked.
Working through a step
The evaluation keeps its steps: Prepare, Evaluate, Plan care and Review. Within a step, the list on the left opens one section at a time (on a phone, the menu at the top). On Evaluate the sections are History and referral, Body map, Examination, Function and mobility, and Assessment - the body map and the examination open beside the note, so you do not leave it. A speech-language evaluation has no body map; for occupational therapy the body map is optional. On Plan care, Goals, Care plan, Home exercises and Outcomes each show the episode's record above the note section that states it.
Each entry shows what it holds in words, such as "1 required section empty" or "2 confirmed". What you type is kept when you switch, and the browser's Back and Forward move between sections. Review shows the whole note as it will be signed.
Sections
An Initial Evaluation started from 1 November 2026 has a Subjective (what the patient reports) and an Objective (what you examined and measured) alongside the evaluation sections, followed by the sections for the episode's discipline and setting. An evaluation started earlier keeps the layout it was started with.
| Field or control | What it means |
|---|---|
| Reason for referral / presenting concern | Why the patient is here, in your words or the referral's. |
| Relevant history (optional) | Past history, in free text. |
| Subjective - patient report | What the patient reports today. In the Evaluate step you can choose a pain score and subjective categories (such as sleep, symptom severity and phase, mood, medications and equipment). Each answer is written into this section as a sentence as you choose it, and changing or clearing it updates that sentence; text you edited yourself is never changed. |
| Objective - examination findings | What you examined today. Confirmed body-map findings, special tests and examination measurements recorded in the Examination section are brought into this section. |
| Functional limitations | What the patient cannot do or has difficulty doing. |
| Clinical assessment | Your clinical reasoning and impression. |
| Measurable goals | The goals in narrative. Goals you track (baseline, target, date) are kept on the episode's goals panel. |
| Plan of care | Planned interventions, frequency and duration in narrative. |
| Field or control | What it means |
|---|---|
| Physical therapy | Mobility, transfers & gait; Balance; Strength & range of motion; Functional movement. |
| Occupational therapy | Occupational profile; Daily activities (ADL/IADL) & participation; Upper-extremity function; Cognition relevant to activities; Adaptive equipment & environmental adaptation. Hand therapy, neurological rehab and paediatric specialties add their own sections. |
| Speech-language pathology | Communication (speech & language); Cognitive communication; Voice & fluency; AAC; Swallowing (when within your configured scope). |
| Outpatient setting | Home exercise program. |
Example (synthetic patient)
| Field or control | What it means |
|---|---|
| On the body map | Knee, left, medial joint line. Guided questions: knee gives way, Yes; stairs difficult, Yes. Special tests: McMurray positive, Lachman negative. Confirmed. |
| Mobility | Stairs, contact guard, observed. Confirmed. |
| Inserted into the note | The confirmed functional limitation goes to Functional limitations; the stairs observation goes to Mobility, transfers & gait. You then write the Clinical assessment yourself. |
| Outcome score | If your clinic has approved LEFS, enter the score you obtained (for example 38) and use Add to note. |
Drafting help: what exists and what does not
| Capability | Status | What that means here |
|---|---|---|
| AI drafting for evaluations, re-evaluations and plans of care | Available | On any unsigned templated note, including an Initial Evaluation, a Re-evaluation and a Plan of Care, the AI action beside a field drafts that section from what the clinician typed, confirmed findings and guided answers, with its sources; too little to draft from gets questions instead. For PT, Draft assessment is shaped by the note type: an evaluation, a visit (follow-up), a progress report and a discharge summary each get their own structure and evidence rules, and a progress report needs an earlier and a current value before it is drafted. OT and SLP assessments keep the general structure. There is no one-click whole-SOAP draft for these notes, and nothing enters the note until the clinician inserts it. |
| Recording a visit or an evaluation | Limited preview | Built into visit notes (Record this visit, Dictate a summary) and into evaluations, re-evaluations, progress reports and discharge summaries (Record this evaluation). Not yet released for routine clinical use. A Plan of Care has no recording.Requires: Switched on for your organisation, the recording permission, and an approved speech-to-text service. |
There is no AI draft for an Initial Evaluation. Where recording is switched on, Record this evaluation lets you record the session; afterwards a rule-based reader (not AI) proposes guided-screening answers, range of motion and strength values, assistance levels, special tests, and the patient's Sleep and Functional limitations answers from the transcript, each with the words it came from. Nothing is recorded until you accept or correct an entry. Accepted measurements and screening answers reach the note text through Add accepted entries to the note; an accepted Sleep or Functional limitations answer is saved in the Subjective categories and added to the note from there. See voice documentation.
After signing
- The text is frozen. Changes are made by amendment, with a reason; the original wording is kept.
- It appears in the episode's note list and under the Initial evaluation chip, as "Initial Evaluation signed" on the episode timeline, and on the patient's Health timeline.
- The episode's structured goals and treatment plan are separate records. Signing the evaluation does not create them; set them on the episode's plan and goals panel.
An evaluation that takes more than one visit
An evaluation is billed once, however many visits it took. On a later visit, the episode's next action is still Resume the evaluation, and it says which visit the evaluation was started on.
- By default the evaluation bills on the visit it was finished on, as Medicare's outpatient therapy billing guidance describes. Signing it on the day of a later visit moves it to that visit first. If you sign it on another day, use Finish on this visit from that visit before signing.
- A practice can instead keep the evaluation on the visit it was started on (Admin > Evaluation billing). Anything else done on the later visit then goes in that visit's own note: use Write today's visit note beside Resume. A service on that visit with no note of its own is held, and the hold says where the evaluation bills.
- A second initial evaluation code on the same episode is held for review. A later formal evaluation is a re-evaluation, with its own note and code.
Limitations
- Nothing is prefilled. Sections are empty until you write in them or insert recorded text.
- Selecting a body region does not change the note's sections or the joints offered for measurement.
- Short-term and long-term goals are not distinguished as separate fields.
- The templates and pick-lists have not been clinically validated by ArkCloud.
- Payer documentation requirements for an evaluation differ; ArkCloud documents its own sections and checks, not what a particular payer expects to see.
Troubleshooting
| Field or control | What it means |
|---|---|
| Initial Evaluation is not in the menu | The episode already has one. Open it from the Initial evaluation chip; amend it if it is signed. |
| No visit to choose | No visit has been started for this episode. Start the visit from the schedule, or choose no specific visit. |
| Sign is refused | Usually the signing requirements: see Review, signing and amendments. |