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Documentation Index

Fetch the complete documentation index at: https://docs.stratapt.com/llms.txt

Use this file to discover all available pages before exploring further.

Clinical documentation in StrataEMR can be started in two ways: directly from the schedule via the clipboard icon, or from the patient’s Clinical Documents page. Both paths lead to the same document creation options — the schedule route just gets you there faster.
Access: Starting and editing clinical documentation requires Clinical Staff permissions or above. Front Desk staff can view clinical documents but cannot create or edit them.

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Starting from the Schedule

The fastest way to begin a note is from the schedule. Click the clipboard icon next to the patient’s appointment on the schedule calendar.
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What happens next depends on the appointment type name: If the appointment type contains eval, progress, discharge, or plan — StrataEMR routes you to the Clinical Documents page, where you choose which type of document to create and how to inherit content. These appointment types correspond to documents that require deliberate decisions about what to carry forward. If the appointment type contains none of those keywords — StrataEMR automatically searches for the most recent completed document with a “General Document” charge type, usually a Daily Note, and either clones it to the current date of service or opens the existing document if one already exists for that date. If no suitable prior document is found, you are routed to the Clinical Documents page.
Appointment type naming matters. The automatic routing from the schedule depends entirely on whether the appointment type name contains a trigger keyword. If your practice uses custom appointment type names, make sure evaluation, progress, discharge, and plan-related visits include the relevant keyword so StrataEMR routes correctly.

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Starting from the Clinical Documents Page

You can also start documentation directly from the patient’s case: Patient Menu Bar > Documents > Clinical Documents. The Clinical Documents page shows all draft and completed documents for the selected patient. To create a new document, select the document type from the dropdown menus at the top of the page — these include clinical templates, outcome measures, pain drawings, and physician letters. Once you’ve selected a template, choose how to create the document:

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Inherit Previous

Pulls content from the patient’s most recently completed clinical document. Goals, diagnoses, medical history, and Plan of Care details carry forward into the new document for you to review and update. Use this for Daily Notes, along with Re-Evaluations, Progress Reports, and Discharge Summaries when you want the current clinical picture of the prior document to carry forward.

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Inherit Patient Intake

Pulls content from the patient’s most recently completed intake form. Demographics, medical history, medications, and allergies pre-populate the corresponding sections of the new document. Use this for Initial Evaluations on patients who have completed an intake form. This saves the clinician from re-entering information the front desk already collected.

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Start From Blank

Uses the template as designed with no pre-populated content. Every section and fragment starts empty. Use this for brand-new patients without an intake form, or when prior content wouldn’t be relevant to the new document type, like a Re-Evaluation with distinctly different fragments than the prior day’s Daily Note.

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Prerequisites for Completing a Document

Before a document can be marked complete and submitted for billing, the following must be in place on the patient’s account:
  • An active insurance policy covering the date of service. If no valid policy exists for the visit date, documentation cannot be completed. See Policies Page.
  • Benefit verification must not be in a pending state. A Pending Benefit Verification task will block document completion until benefits are confirmed. See Authorization Management.
  • Authorization on file if the policy requires it. If authorization is required and none is entered, documentation cannot be completed.
  • A referring provider with NPI for all Medicare patients. Claims cannot be submitted for Medicare patients without a referring provider listed.

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Cloning a Document

Once a document is completed, future notes of that same type can be cloned from it rather than created from scratch or through inheritance. Click the blue clone button next to the document you want to copy. The clone creates an exact copy of the document without the date of service — update the clinical content for the current visit and complete as normal. One common use for this workflow is the creation of subsequent re-evaluations after the first has been completed, for example in pediatric care where a therapist may conduct multiple re-evaluations over the child’s total episode of care.