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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.

Every patient encounter requires a corresponding clinical document to support the claim during the approval process. StrataEMR enforces signing rules and role-based restrictions to ensure documentation is compliant, complete, and associated with the correct provider before billing occurs.
Access: Clinical Staff and above can create and sign clinical documents. A non-assistant staff type is required to receive review tasks and complete documents requiring supervisor sign-off.

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Document Task Ownership

Ownership of documentation-related tasks is tied to the schedule. The therapist scheduled for the appointment’s date of service is the initial owner of any related draft and clinical tasks. Ownership transfers occur when another clinician edits an existing document — the last person to edit the note takes ownership of all related tasks. This ensures the correct clinician is accountable for completing and signing the document. To view your clinical tasks, navigate to the Tasks page from the blue Menu Bar and select the Clinical tab. Use the Staff filter dropdown to see tasks assigned specifically to you.

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Understanding Color Codes in Documents

As you complete a document, text color indicates the status of each field:
ColorMeaning
RedRequired — document cannot be saved as Complete without this information
BlueRecommended — not technically required but should be completed for thorough documentation
GreenInherited — information carried forward from a prior document or intake form
Any selector that has not been updated will appear in the completed document. Remove fragments that don’t apply to the care provided rather than leaving them blank.

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Charge Advice

Once clinical content is entered, complete the Charge Advice section at the bottom of the document:
  • Enter all relevant CPT codes, units, and minutes for the encounter
  • Confirm the Place of Service has carried over correctly from the patient’s Case Info
  • For assistants: Select Assistant Involved on the far right for any CPT codes you administered — this applies the required billing modifiers (GP/GO/GN) automatically

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Enhanced Document Signature Compliance

StrataEMR’s optional Enhanced Document Signature Compliance feature enforces strict rules on how documents are signed and completed. Critical rules:
  • Logged-in user requirement — A document can only be marked Complete if the signature of the currently logged-in user is included on the document. You cannot complete a note signed only by someone else.
  • No automatic signature carry-over — Signatures do not carry forward from prior documents. Every note requires a fresh signature for that encounter.
  • Easy selection — Your own signature appears at the top of the signature dropdown by default to prevent mis-clicks.
If you are interested in enabling this feature for your clinic, please reach out to your StrataPT account manager.

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Role-Based Restrictions

Template-level restrictions ensure the correct provider type signs specific document types:
Document TypeSigning Restriction
PT Initial Evaluations, Progress Notes, Discharge SummariesMust include a Physical Therapist signature
OT Initial Evaluations, Progress Notes, Discharge SummariesMust include an Occupational Therapist signature
Daily Treatment NotesCan be completed by PT, PTA, OT, or COTA
These restrictions are set at the template level and apply across all patients — they cannot be overridden on individual documents.
State-specific requirements vary. PTA and COTA co-signing requirements differ by state and sometimes by payer. Consult your state practice act and legal counsel for edge cases not addressed by StrataEMR’s default template restrictions.

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Workflow for Assistants (PTA/COTA)

Every clinical document requires a supervising therapist’s NPI on the note, regardless of who treats the patient. The workflow depends on your clinic’s policy: If your clinic requires supervisor review before completion:
  1. Complete all clinical content and enter Charge Advice — select Assistant Involved for applicable CPT codes
  2. Select your supervising therapist in the signature section
  3. Save the document as Draft — do not mark it Complete
  4. Use the dropdown next to the document status to generate a Review Documents task for your supervisor
  5. The supervising therapist opens the task, reviews, adds their signature, and marks the document Complete
  6. Billing triggers after the supervisor completes the document
If your clinic allows assistants to complete daily notes directly:
  1. Complete all clinical content and Charge Advice — select Assistant Involved
  2. Ensure the supervising therapist’s signature or name is included on the document
  3. Mark the document Complete
Billing always submits under the supervising therapist’s NPI, regardless of who completes the document. Ensure the correct supervising therapist is identified on every note.