Physical therapy dictation software for evaluations, daily notes and progress reports

Most physical therapists document after the patient leaves, at lunch, or at home after the last visit. The assessment and the plan take longest to type, because they are written in sentences that have to show why skilled care is needed. General dictation tools were not built for "goniometry", "antalgic gait" or the Berg Balance Scale. The Healthcare dictionary in VoicePrivate has 1,968 PT and rehabilitation terms, with orthopedic and neurology terms alongside.

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Notes physical therapists dictate

Initial examination and evaluation

History, systems review, tests and measures such as range of motion by goniometry, manual muscle testing and the Berg Balance Scale, then the evaluation, diagnosis, prognosis and plan of care with goals.

Visit or daily note

Interventions with their parameters, such as therapeutic exercise, joint mobilization, neuromuscular electrical stimulation and gait training, how the patient responded and any change to the plan.

Reexamination or progress report

Retesting against the initial measures, progress toward each goal and why skilled care is still needed.

Conclusion of the episode of care

Discharge summary with goal status, the home exercise program and follow up recommendations.

These four follow the main documentation elements the American Physical Therapy Association lists: initial examination and evaluation, visit, reexamination, and conclusion of episode of care summary. Payers such as Medicare Part B add their own requirements on top.

Physical therapy words general dictation gets wrong

The Healthcare dictionary stores the mishearings it corrects. A few from the physical therapy list:

• "goniometree" to goniometry
• "hemiplagia" to hemiplegia
• "propriocetive neuromuscular facilitation stretching" to proprioceptive neuromuscular facilitation stretching
• "dexamethasone iontoforesis" to dexamethasone iontophoresis
• "achilles tendinopathey" to achilles tendinopathy
• "ekwinus gait" to equinus gait
• "lymfedema pump" to lymphedema pump

What choosing PT / Rehabilitation does

On Mac, open Settings and set the Medical specialty to PT / Rehabilitation. Recognition is then primed with its core terms: range of motion, abduction, quadriceps, hamstring, antalgic, ambulation, front wheeled walker, Berg Balance Scale, proprioception, neuromuscular electrical stimulation, therapeutic exercise, patellar mobilization, straight leg raises, heel slides, quad sets, adhesive capsulitis, joint mobilization, home exercise program, activities of daily living and occupational therapy. A long misheard word that is a near miss of one of those terms is matched to it first. On Windows there is no picker and the full medical dictionary is used for every note.

The same list covers occupational therapy terms such as activities of daily living, so OTs on your team can use the same setting.

Example: a daily note after a total knee replacement

Click into each field of the note, press the hotkey, speak, and press the hotkey again. The text is pasted when you stop.

1. Subjective. Press Command+Shift+Space and say: "Three weeks status post right total knee arthroplasty. Pain 3 out of 10. Walking in the house without the front wheeled walker." Press the hotkey again.
2. Objective: press Command+Shift+Space and say: "Knee range of motion 5 to 105 degrees, up from 10 to 95 last week. Quadriceps lag on straight leg raises resolved. Mild antalgic gait." Press the hotkey again.
3. Interventions: press Command+Shift+Space and say: "Therapeutic exercise 25 minutes: quad sets, heel slides and stationary bike. Patellar mobilization and tibiofemoral joint mobilization 10 minutes. Neuromuscular electrical stimulation to the quadriceps 10 minutes." Press the hotkey again.
4. Assessment and plan: press Command+Shift+Space and say: "Progressing toward the goal of 115 degrees of flexion. Continue 2 times a week for 4 weeks. Home exercise program updated." Press the hotkey again.

Into your EMR

VoicePrivate pastes through the clipboard and then puts back what you had copied, so there is nothing to install inside the EMR. It works in any text field that accepts a paste, which covers the narrative fields of hospital EHRs and outpatient rehab EMRs. Drop-downs, check boxes and flowsheet grids are still faster by hand. If your EMR runs in Citrix or another remote desktop, the session must allow clipboard redirection from your computer. The EHR dictation guide covers the common setups.

Many daily notes repeat the same sentences, such as a statement that the patient tolerated treatment well or a home exercise program review. Text shortcuts expand a short phrase into that full paragraph, which you then edit for the patient in front of you.

On-device facts

Speech is processed on the Mac or Windows PC that runs VoicePrivate. Audio never leaves that computer, and nothing is sent to a cloud service for transcription. There is no recording of the treatment session: you dictate the note yourself after or between patients. With Auto-save transcriptions on, which is the default, each dictation is also kept in the app's Library on that computer. Turn it off in Settings if you want the record system to hold the only copy.

Price

Healthcare Edition is $297 a year or $34.99 a month per clinician. There is no free trial. Individual monthly and annual plans have a 30-day money-back guarantee on the first payment. Clinics of 2 to 20 clinicians can buy team seats.

Physical therapy dictation FAQ

Physical therapy works alongside orthopedic dictation for post-op referrals and pain medicine dictation for spine patients. Rehab teams that include speech therapy can point their SLPs to speech-language pathology dictation.