One clinic. Many disciplines. Keep the care connected.

AI documentation for rehabilitation clinics and their care teams. Turn evaluations, therapy sessions, and team handoffs into clear notes in the formats your team uses.

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A common documentation approach across your rehabilitation team

  • Physiotherapy
  • Occupational therapy
  • Speech-language therapy
  • Multidisciplinary teams

From first evaluation to discharge. A record for every stage.

Keep the whole episode of care in view. Capture the starting point, track each session, and bring goals and progress together in the next update.

  1. Initial evaluation

    Evaluation note

    In the record
    Referral context, the patient’s priorities, baseline findings, functional limitations, and the clinician’s assessment.
    Carry forward
    A clear starting point, goals to track, and a plan for the next session.
  2. Treatment session

    Therapy progress note

    In the record
    The patient’s update, activities or interventions completed, recorded findings, response, and any changes to the agreed plan.
    Carry forward
    A home-program summary and a session update for the next team member.
  3. Reassessment

    Reassessment note and progress letter

    In the record
    Current findings alongside the relevant baseline, the status of each functional goal, and the clinician’s interpretation of progress.
    Carry forward
    A progress letter for the referrer or care team, with current goals and next steps.
  4. Discharge

    Discharge summary

    In the record
    The end-of-care status, goals reached, remaining priorities, and the ongoing plan.
    Carry forward
    Patient instructions and a referrer summary that explain what happens after clinic visits finish.

Standardize the essentials. Keep each discipline’s perspective.

Give your team a common starting point. Use the template previews below to shape your notes, then import or build the format each discipline needs in Vero Scribe.

Physiotherapy progress template

Editable clinic template

Patient priority
The activity the patient wants to return to and the update they gave today.
Recorded mobility and measures
Mobility findings, activity tolerance, and measures alongside the previous session.
Interventions and response
Activities completed, relevant observations, and the patient’s recorded response.
Clinician assessment
The treating clinician’s interpretation of the findings and progress toward the goal.
Home program
Session instructions, home activities, and updates to the patient’s plan.
Next session and handoff
What to revisit, which document to prepare, and which team member needs the update.

The goal stays the same. The next clinician adds a perspective.

Connect the walking progress in a physiotherapy note with the everyday activities in an occupational therapy session. A concise handoff brings the patient’s goals, latest update, and next step together.

Physiotherapy → Occupational therapy

J. Morgan · Example handoff

Purpose of the handoff
Bring the patient’s stair difficulty and goals for home activities into the next occupational therapy session.
Recorded physiotherapy context
Patient reports reaching the café and walking for 20 minutes, up from 10 minutes at the initial visit. A handrail is still used on stairs.
Focus for the next session
Explore which everyday activities at home remain difficult. Add task observations, the occupational therapy assessment, and next steps to the session note.
Team communication
Use the handoff summary for the next appointment and send a progress letter to the referrer through the clinic’s usual communication process.

A clear next step for the team

  1. Physiotherapy: carry the session forward

    Bring the walking update, current goals, and remaining stair difficulty together in a concise handoff.

  2. Occupational therapy: add everyday context

    Connect the update with home routines and daily activities, then add the next session’s findings and plan.

  3. Clinic team: keep communication moving

    Send the progress letter to the referrer and coordinate the next appointment through the clinic’s usual process.

One session. Three useful documents.

Turn session details into a progress note, a letter for the referrer, and a summary for the patient. Keep each document focused on what its reader needs next.

Example therapy progress note

J. Morgan · Knee rehabilitation · Progress visit

For the clinical record
Subjective
Patient walked to the local café this week. Stairs remain difficult. Goals are comfortable community walking and managing the stairs at home.
Objective
Patient-reported walking tolerance: 10 minutes at the initial visit, 20 minutes today. Handrail used on stairs. Session activities and response added to the progress note.
Assessment
Community walking has improved. Stairs remain a priority for the next session and occupational therapy handoff.
Plan
Continue the current plan. Prepare a home-program summary, an occupational therapy handoff, and a progress letter for the referrer. Revisit walking and stairs at the next session.

Session excerpt

“I made it to the café, but the stairs are still difficult.”

Recorded functional progress

Walking tolerance
10 minutes20 minutes
Community walking
Café is a goalCafé reached
Stairs at home
Handrail usedStill a priority

Rehabilitation progress letter

For the referring clinician
Re
J. Morgan · Rehabilitation progress update
Goals & recorded change
Goals are community walking and managing stairs at home. Patient reports reaching the local café and walking for 20 minutes, compared with 10 minutes at the initial visit. A handrail is still used on stairs.
Ongoing plan
Continue the current plan. The next session will revisit walking tolerance and stairs at home. Occupational therapy will add context about everyday activities.

Your progress and home program

For the patient
Your progress
You made it to the café this week and told us you can walk for longer. Stairs are the next goal to revisit together.
Between sessions
Your home-program summary brings together the activities discussed in your session and your goals for the week.
At your next visit
We’ll talk about walking, stairs, and how your home program fits into your week.

Find answers for your clinic’s workflow.

Explore documentation questions with Vero Evidence. Ask about progress notes, outcome tracking, or template structure, and get cited answers your team can explore in one workspace.

  • Questions about rehabilitation documentation
  • Cited answers in one workspace
  • Useful context for your clinic’s templates
Explore Vero Evidence

Start with one clinic workflow. Learn what your team needs.

Choose a familiar care pathway, set up your templates, and try them with your team. Refine the notes and handoffs as you learn what works for your clinic.

  1. Choose one pathway

    Start with a familiar sequence of evaluations, progress visits, and reassessments. Bring a few everyday sessions into the pilot.

  2. Agree on the core fields

    Keep patient priorities, session context, recorded findings, clinical assessment, and next steps consistent. Add the fields each discipline needs.

  3. Try the notes together

    Compare the notes and documents with your current workflow. Refine the length, useful detail, and editing steps with your team.

  4. Set the handoff process

    Choose who sends each update, how it reaches the next team member, and who keeps the templates current as your clinic grows.

Explore the work of each discipline.

Explore notes, templates, and everyday workflows for the disciplines in your clinic.

Questions from rehabilitation clinics

Practical details about team templates, progress letters, handoffs, and getting started.

Which rehabilitation teams can use this clinic workflow?

Vero supports documentation for physiotherapy, occupational therapy, speech-language therapy, and multidisciplinary rehabilitation teams. Your clinic can use a common structure for patient goals and session updates, with separate templates for each discipline.

Does every discipline have to use the same template?

No. Agree on a common core such as patient priorities, session context, recorded findings, clinical assessment, and the next step. Each discipline can use a different template with its own sections and terminology. Vero Scribe lets you start with a template, import a format, or build your own.

How should templates change from evaluation to discharge?

An evaluation captures the starting point and goals. A treatment note brings together session activities, findings, and response. A reassessment compares progress with the baseline. A discharge summary brings together the end-of-care status and ongoing plan. You can build a template for each stage in Vero Scribe.

What belongs in a handoff between physiotherapy and occupational therapy?

Bring together the patient’s goal, the latest session update, relevant findings, and the focus for the next appointment. Vero Documents can turn that context into a concise handoff summary for your clinic’s usual communication process.

How can our team keep progress comparisons clear?

Use consistent fields for goals, patient updates, measures, and session dates. Add the previous and current findings to the session context, and Vero can organize the comparison in your chosen note template or progress letter.

Can patient instructions reflect the plan agreed during a session?

Yes. Vero Documents can turn session details into a patient summary or home-program document. Bring together the activities discussed, the patient’s goals, and the next appointment’s focus in clear, everyday language.

Can we prepare progress letters for referring clinicians?

Yes. Vero Documents can help create a progress letter from the session context. Include the original goals, changes since the last update, current priorities, and next steps. Edit the letter in your preferred format and send it through your clinic’s usual process.

What is a practical way to start a clinic pilot?

Choose one familiar care pathway and a few everyday sessions. Set up the common fields, adapt each discipline’s template, and try the notes and documents with your team. Start with the free plan or contact Vero to discuss clinic workflows and onboarding support.