Objective

On the episode, the body map lets you choose a region and side, then tick findings from that region's lists. Selecting a region changes the pick-lists, guided questions and special tests offered. The full description, with region examples, is on Body map and guided assessment.

Rehab → Episodes → open the episode → Evaluation → Anatomical findings

Each region on the body map has a Special tests list. For each test you performed, choose Positive, Negative or Inconclusive. The panel says: "Record the tests you performed and what each showed. ArkCloud does not suggest which tests to perform, and does not interpret a result."

The lists are draft suggestions awaiting clinical review. They are not a protocol, and you are not expected to perform every test for every patient; leave a test blank if you did not do it. A test absent from the list is written in the note.

In Quick Capture on a visit note, under Measured today, choose Range of motion, then joint, motion, side, AROM or PROM, and degrees (from -90 to 360; a deficit such as an extension lag is negative). Nothing is pre-selected.

There is no thoracic range of motion. Each value is stored as a measurement; the note shows the earlier value beside today's when one exists, and says "none recorded" when it does not.

In the examination, the i beside a shoulder, elbow, forearm, wrist, hip, knee or ankle motion opens its adult reference value (AAOS averages as tabulated by Norkin and White), with the units, population, method, source and what the figure cannot tell you. It is context, not a cut-off: nothing is labelled abnormal, and nothing from it is written into the note. Spinal, digit and ankle inversion/eversion motions show no reference, because no single published value applies. Manual muscle testing shows why a grade has no numeric normal. The reference content awaits review by a clinician at your clinic.

Choose Strength (MMT), then joint, motion and side, and a grade: 0, 1, 2-, 2, 2+, 3-, 3, 3+, 4-, 4, 4+ or 5. The note writes it over five, for example "Strength (MMT) left knee extension 4-/5."

For hand and upper-limb work: grip and lateral, tip and three-jaw pinch by dynamometer in pounds or kilograms (up to 500); edema in centimetres, inches or millilitres; and sensation by monofilament or in millimetres. Each reading keeps the unit it was taken in; nothing is converted. Named hand instruments such as the Nine-Hole Peg Test are not administered in ArkCloud - their scores are entered on the outcome measures panel.

The episode's Mobility and assistance panel records one activity at a time: rolling, supine to sit, sit to supine, sit to stand, bed to chair, toilet and car transfers, walking on level and uneven surfaces, stairs, wheelchair mobility, standing balance, dressing, bathing, toileting hygiene, and functional tasks such as reaching forward or overhead, lifting from the floor, squatting and carrying.

1. Choose the activity.
2. Choose the level: Independent, Modified independent, Supervision, Contact guard assistance, Minimal, Moderate or Maximal assistance, or Dependent / total assistance. There is no default. Not attempted requires a reason.
3. Say whether you observed it or the patient reported it.
4. Tick any observations for that activity - for walking, gait patterns such as Antalgic gait pattern, Trendelenburg gait pattern or Reduced foot clearance / toe drag; for stairs, One step at a time (non-reciprocal) or Used the handrail; for standing balance, Postural sway or Unable to maintain single-leg stance.

Functional goals use the same levels. On an evaluation, progress report or discharge summary,Functional levels records the prior, current and goal level for each activity from one list, which also offers Unable / not performing and Not assessed. Not assessed is an unknown, not a limitation, and neither it nor Unable can be a goal. In Goals, choosing an activity makes it a functional goal: pick the starting and target level, and optionally an assistive device, a measurable amount (feet, metres, steps, repetitions, minutes, seconds or % of trials) and a target date. A goal level recorded on the latest note can be used as the starting point, and the goal sentence can be written from your choices; you still propose or accept the goal. The current level on a signed note counts as progress toward the goal on the same activity.

These levels are not CMS Section GG codes. The PT note sections Mobility, transfers & gait, Balance and Functional movement are free text; confirmed mobility observations can be inserted into them.

Scores from standardised instruments (for example LEFS, TUG or Berg Balance Scale) are administered outside ArkCloud and entered as scores once your clinic has approved the instrument. See Outcome measures.

• Quick Capture sides: Left, Right, Bilateral, Not applicable. Choose one for every measurement.
• On the body map, limb regions and the sacroiliac region ask for a side; the cervical, thoracic and lumbar spine, head, chest, abdomen and pelvis do not.
• A left and a right knee are separate sites with separate findings.
• An AI draft removes any sentence whose side is not in what was recorded, or that puts a value on the wrong side.

• Body-map findings are either selected (saved without confirming) or confirmed under your name. Only confirmed findings can reach a note.
• Mobility observations are labelled observed or patient-reported.
• Nothing defaults to a normal finding. A blank stays blank; leave a section empty if you did not assess it.
• Opening a region ticks nothing; only a Yes to a guided question, or your own tick, does.
• Voice proposals from an evaluation recording are marked as clearly heard or uncertain, and none is stored until you accept or correct it.

• The joint I chose on the body map is not preselected in Quick Capture: expected. The two are not linked today.
• A body-map finding is not in the note: it is selected, not confirmed. Confirm it, then add it to the note.
• Saving a finding fails with "Structured anatomy recording is not enabled": saving body-map and mobility entries is switched off for that deployment. It is on for the hosted service.