Sources: Allen OT Orientation Packet (2021); LatestPTTemplate (current PT note); Original Epic note templates; personal smartphrase library; "Epic from Start to Finish 3.0" and "Inpatient Therapies Notes" job aids.
The current inpatient PT template (SmartLink-driven; pulls flowsheet data automatically) follows this skeleton — free-text fields are marked ***:
Header: patient name, MRN, session date/time, preferred language, chart reviewed, total treatment time, current location, interpreter services, isolation, diagnosis
Hospital Course Update — "PT IE Completed" + HPI (age/sex, admit date, ***), PMH/PSH SmartLinks
Home Living — living situation, devices/equipment
Prior Level of Function — home/community mobility, ADLs/iADLs, work status, patient-stated goals ***
Subjective — patient report ***, pre-treatment pain
Objective — general observations (position, location, lines), mentation/vision/ hearing, vitals, tests & measures (endurance, balance, ROM, MMT, skin, sensation, neuro, cardiopulmonary, vestibular, posture; add sections with .PTADDTESTSANDMEASURES), outcome measures, functional mobility
Interventions — comments, treatment time and statistics
Education — @PTPTED@ Goals — @PTCAREPLAN@
Assessment — post-treatment pain, impairments, tolerance, post-session observations, impression ***
Plan — plan, treatment plan, response to plan, plan-of-care discussed with / items discussed, signature (@ME@, DPT) and date/time
Rehab-unit variants exist for evaluation/re-evaluation, treatment, and discharge summary (the discharge summary adds a Quality Indicators section). OT parallels: evaluation/re-evaluation, treatment, reassessment, and DC summary templates.
| Phrase | Use |
|---|---|
.OTACUTEALL |
Populates the OT note templates — initial evaluation, treatment, and non-treatment notes. |
.eval |
"Patient tolerated initial OT evaluation fairly well. Patient was cooperative and motivated for session." |
.cont |
"Will continue to follow and treat as appropriate." |
.none / .homeot / .sar |
Discharge recommendation: no follow-up / Home OT / SAR. |
.acute |
Must appear in the impression for every patient recommended for acute rehab. |
.prec |
Documents education on spinal precautions. |
.kit |
Documents providing the spine kit. |
.glasses |
Documents providing prism glasses to a spine patient on flat bedrest. |
.kettle / .moca (.mocaresult) |
Documents administering the Kettle Test / MoCA. |
| Phrase | Expansion |
|---|---|
6MWT |
"Patient completed 6 minutes of walking. A total of __ feet was completed, with rate of perceived exertion (RPE) rating of __. This walk distance is __% of predicted for a person of this gender, age, height and weight. No rests were taken… max HR of __ and oxygen saturation of __% on room air…" |
AMS |
"Pt currently with altered mental status, likely at baseline, will require adapted education/family based education." |
COMMODE / TOILET |
"PT had visual contact of high fall risk patient 100% of the time while using the bedside commode / being toileted." |
DCCPT |
"Based on ___, patient not appropriate for skilled Chest PT at this time. Could benefit from turning schedule and standard pulmonary toileting as tolerated. Please re-consult if… change in status…" |
INDEPENDENT |
"At this time, the patient is not appropriate for skilled PT due to functional independence, and is discharged from the service. No further f/u is recommended post discharge." |
DCPT |
"As per chart, patient is s/p ___, will require new PT/OT orders to continue therapy. Please re-consult once appropriate." |
_OTFIRSTLASTNAME; add columns: unit, bed, patient name, MRN, attending, age/gender, OT received-on date, new OT orders, OT/PT treatment team, order dx, OT/PT discharge recommendations, assigned nurse, specialty comments, today's charges, handoff action list, handoff patient summary, has-bed-rest-order, isolation/infection..OTLTG for long-term goals.Source: Acute Care PT New Hire Epic Checklist (May 2025)
!PT First Last list (Edit List → Create My List; copy columns from an existing list). Under Advanced, give triaging therapists access — level 5 for main triagers (can manipulate), level 2 for view-only. Drag "All My Patients" onto the new list to populate it.Full job aids live in the department drive (Epic Stuff/epic): "Epic from Start to Finish 3.0" (end-to-end workflow), Inpatient Therapies Notes / Navigator / Flowsheets / Charging, Rover tip sheets (voice, alerts, secure chat), Care Plan Activity guide, planned/unplanned discharge documentation-only note process, and the smartlist master list. The clinical team site adds: Epic flowsheet-code spreadsheets, the "How To Use NYCTHPYFLOW SmartLink" reference image, Epic Notecraft/SmartTool course books (CLN/MD series), and the "Bending the Note Curve" note-bloat workshop.