Visit note (SOAP)

For every treatment visit. Write it against the visit it documents: that link is what lets signing move the visit from "waiting on documentation" to ready to bill, or held with a reason. A visit can have only one open visit note at a time; if one exists, Start opens it instead of creating a second.

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

1. In New document, choose Visit note, choose today's visit, and press Start.
2. In Quick Capture, record the visit by selection as you go: pain score and where, change since the last visit, what the patient reports, range of motion and strength by joint and side, interventions with their focus, tolerance, and goal progress. SLP and OT episodes also offer their own capture (speech trials and swallowing; orthoses and caregiver training). Selections save as you tap.
3. Under Treatment activities, list what was done (exercise, sets and reps, resistance, assistance, response). Start from last visit offers the previous visit's activities as unticked rows; only rows you tick are added, and the response is left blank for you.
4. Fill the note in one of three ways, or mix them:
   • type each section yourself;
   • Build from your selections (no AI) turns your Quick Capture into note text by fixed rules;
   • Draft SOAP note asks the AI for a draft, shown beside the note. Use Insert, Add below yours or Replace yours per section; an insert can be undone.
5. Check Objective - interventions provided: it is what a biller reads to match the services recorded for the visit.
6. Press Sign. If the note holds AI-drafted text, tick the review statement that appears and sign again. Review anything the sign check lists, then sign or press Sign anyway.

Each section is covered in the SOAP guide.

What it reads. Today's capture and any notes, assessment and plan you typed in the panel, your dictated summary if you recorded one, 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. It is not sent the patient's name, date of birth, MRN, address, payer or charge amounts.

What it checks. A sentence with a number, side or assistance level its sources do not contain is removed, and you are told how many were removed and why. A section that cannot rest on today's information is left empty. Missing information stays missing.

Where your clinic uses the patient AI agreement, the draft is refused for a patient who has not signed it or who answered no; use Build from your selections instead. More in AI-assisted drafting.

Where recording is switched on and you hold the recording permission, a visit note shows Record this visit (everyone present agrees first) and Dictate a summary (you alone). A visit transcript is added to the draft's notes box marked unverified; a dictated summary becomes a source for the draft. Nothing goes into the note or is signed by itself. See voice documentation.

• The text freezes. Changes are amendments with a reason.
• The visit's billing readiness is refreshed: ready to bill, or held with a reason. Nothing creates a charge automatically. A charge is created only when someone with fee-management permission uses Post charge in charge capture; interventions and activities in the note never create or change a charge.
• The note shows in the episode's list beside its visit date and under the Visit note chip, on the episode timeline, and on the patient's Health timeline.

• Values from the previous visit are never copied forward. Start from last visit offers activities only, unticked.
• Service-group labels show the code a group is commonly documented under. They do not establish billability.
• A blank required section does not stop signing, but the visit is held from billing as note incomplete.
• Pick-lists are draft vocabularies awaiting clinical review.