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Clinical Intelligence

Session notes that score, code, and write themselves.

Session note software for therapy practices, with CPT coding built in. CPT-aligned session notes with optional AI drafting from structured observations. GPI and SPI scoring per session. Response to Intervention tracking built in.

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Overview

Session documentation in MyTherapyWizard takes about thirty seconds per goal addressed. For each goal you worked on, you capture: correct out of attempted, cues level, level of assistance, and any goal-specific challenges that showed up during the session (attention, regulation, fatigue, sensory factors).

From those inputs, the system calculates a Goal Performance Index, a number that combines how well the client performed against the target with how much support was required to perform at that level. A client scoring 70% accuracy independently produces a different GPI than a client scoring 70% accuracy with maximum assistance, because those are clinically different events. The math reflects that.

The Session Performance Index averages GPI across the goals addressed in a single session. CPT code, units, and rendering provider capture at the same time, so the claim is ready to generate the moment the note is signed. No post-hoc coding, no claim-builder tab to revisit, no reconciling the note with the bill.

How it works

Under the hood.

The technical architecture, API integration points, and data model that make this feature work the way it does.

01

GPI calculation: performance against target × support level.

Goal Performance Index combines the two dimensions that matter clinically, accuracy/frequency/rate/duration/completion against target, weighted by level of assistance and cue intensity required. 70% correct with max assist ≠ 70% correct independently. Same target, different GPI.

02

SPI aggregation per session.

Session Performance Index averages GPI across goals addressed in the session. Rolls up to per-session and longitudinal per-client views. Produces the trajectories progress reports compose from.

03

Full row navigable to note editor.

Session note rows on the Therapy Record are fully clickable, date/time, type, goal area, status badges (Signed, Finalized, Unsigned, No code, Co-signed, CPT code). One click opens the note directly.

04

Co-sign workflow per insurance rules.

Org Flow Settings supports per-therapist × per-insurance × per-CPT co-sign rules. When a rule requires co-sign, the supervising therapist sees the note on their worklist; the co-signed badge appears after supervisor signature.

Why it matters

01

Measurement, not prose.

Every session you run adds structured data points to every goal's trajectory. Your documentation isn't just a record of what happened, it's a measurement of what happened, comparable over time.

02

CPT captured at the point of session.

Billing-ready the moment the note is signed. No separate coding pass, no claim-assembly step, no 'what did you do in that session again?' follow-up email.

03

Status badges visible on every note row.

Signed, Finalized, Unsigned, No code, Co-signed, CPT code. Unsigned notes flag 'Action needed' in red on the Therapy Record, gaps close as they happen, not at end-of-period.

See session notes inside MyTherapyWizard.

Book a 30-minute walkthrough with our clinical team. We will show the exact workflow for your discipline and caseload.