chiropractor pt ot documentation kit
Generate audit-ready clinical documentation, SOAP notes, and measurable goals for rehab clinicians.
$5
Works with the AI tools you already use
Claude Code
Cursor
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Grok Bot+18 agentschiropractor pt ot documentation kit
Example session with this skill installed
Generate a SOAP note for visit #4. Patient reports 6/10 shoulder pain during overhead reach. Objective: R shoulder flexion AROM 105 deg, MMT 3+/5. Performed 3 sets of 10 wall slides. Assessment: progress is steady but limited by scapular stability. Plan: increase load next visit. CPT: 97110.
- Read your context and instructions
- Compiled the chiropractor pt ot
- Generated the document
Documentation for visit #4 is prepared. The note captures the objective ROM and MMT findings while linking the assessment to functional limitations for audit compliance.
Clinical Documentation: SOAP Note
Patient Identifier: PT-9982
Date: October 24, 2023
Visit Number: 4
Clinician: [Clinician Name], PT, DPT
Subjective (S)
Patient reports persistent right shoulder pain, currently rated at 6/10 on the numeric rating scale. Pain is specifically provoked during overhead reaching tasks at home (e.g., reaching for items on high shelves). Patient notes no significant changes in resting pain levels since visit #3.
Objective (O)
- AROM: Right shoulder flexion 105° (measured via goniometry).
- MMT: Right shoulder flexion 3+/5.
- Therapeutic Exercise: Wall slides, 3 sets of 10 repetitions, focusing on eccentric control.
- Manual Therapy: Grade II glenohumeral joint mobilizations for pain modulation.
Assessment (A)
Patient is demonstrating steady objective progress in active range of motion, though functional gains remain limited by deficient scapular stability and rotator cuff weakness. Skilled intervention focused on neuromuscular re-education and joint mobilization to address impingement symptoms. Patient is responding well to current interventions but requires continued skilled PT to reach functional flexion goals required for ADLs.
Plan (P)
Continue current frequency of 2x/week. Next visit will focus on increasing load during scapular stabilization drills. Monitor for increased soreness following today’s progression. HEP remains unchanged.
Codes
CPT: 97110 (Therapeutic Procedure)
Next steps
- Review the objective measurements for accuracy against your treatment log.
- Insert your digital signature for the medical record.
- Submit the assessment section to the billing coordinator for authorization tracking.
chiropractor-pt-ot-documentation-kit.pdf
PDF · document
Example file from a real run - the skill writes it into your workspace.
Connects securely to your tools. The creator never sees your data.
What you get
About this skill
The problem
Rehab clinicians spend hours on documentation that must satisfy strict payer audits. Vague notes lead to denied claims, while manually drafting medical necessity narratives and functional goals is a massive time sink.
What it does
- Generates audit-ready SOAP notes with clear Subjective, Objective, Assessment, and Plan sections.
- Drafts Initial Evaluations including medical necessity narratives and functional limitations.
- Constructs measurable, functional, and time-bound short-term and long-term goals.
- Produces Plan of Care recertifications that justify continued skilled intervention with objective data.
- Writes prior authorization appeals and discharge summaries grounded in clinical reasoning.
Why this beats prompting it yourself
Standard LLM prompts often produce generic, flowery, or non-clinical language that fails payer reviews. This skill enforces specific documentation principles like minimal clinically important difference (MCID) references and impairment-to-function goal structures. It ensures every note focuses on skilled-services justification rather than just listing activities.
Use cases
- Converting messy session shorthand into professional, billable SOAP notes.
- Drafting complex medical necessity narratives for Medicare or workers' comp initial evals.
- Updating Plan of Care goals for 30 or 60-day recertification cycles.
- Creating patient-facing HEP letters that translate clinical jargon into plain language.
Known limitations
Does not select CPT or ICD-10 codes. Cannot diagnose conditions outside of licensed scope or invent objective measurements like ROM degrees or MMT grades.
How to install
Works the same in every agent - Claude, Cursor, Codex, Copilot and 20+ more.
- 1
Download the ZIP
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- 2
Unzip into your skills folder
Every agent reads skills from one folder on your machine. Drop the unzipped folder in there.
- 3
Ask your agent to use it
Restart the agent if it was already running. It picks the skill up automatically - no config needed.
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Click the path to copy it. Create the folder if it does not exist yet.
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