Medicare pays for therapy that is reasonable, necessary, and skilled. "Skilled" means the service is complex enough that it needs a therapist, not just anyone who could supervise an exercise. Your note has to show that. If it only says the patient did something, it can look unskilled even when you did skilled work.
This guide walks through what separates the two, with made-up examples for SLP, PT, and OT. Adapt everything to your own judgment and your facility's policies.
What "skilled" looks like in a note
A note reads as skilled when it shows things only a therapist could do:
- Clinical judgment. You chose, adjusted, or stopped something because of how the patient responded.
- Specific technique. You cued, modeled, graded, or taught in a way that took training.
- Assessment. You observed something specific and acted on it.
- Measurable response. You recorded data tied to a goal.
- Instruction. You taught the patient or a caregiver and checked that it worked.
A note reads as unskilled when it only reports that a task happened, repeats the last note, or could describe a routine activity anyone could supervise. ASHA publishes examples of skilled and unskilled notes for SLPs, and it makes the same point: skilled care that isn't described well can look unskilled.
Speech-language pathology
Weak"Pt practiced word finding. Pt did well. Continue POC."
Stronger"Pt seen for language treatment targeting naming of functional items (STG 2). Clinician used semantic feature analysis, cueing pt to describe category, use, and location before naming. Pt named 7 of 10 items with min cues, up from 4 of 10 last session. Clinician reduced cue frequency after 5 consecutive correct responses. Plan: begin carryover with items from pt's room next session."
Physical therapy
Weak"Pt ambulated 100 ft with rolling walker. Tolerated well."
Stronger"Pt seen for gait training targeting safe household ambulation (STG 1). Clinician provided tactile and verbal cues for step length and upright posture and monitored heart rate and oxygen saturation given recent cardiac history. Pt ambulated 100 ft with rolling walker and contact guard assist, needing 4 cues for posture, down from 8 last session. Clinician lowered the walker height after noting forward trunk lean. Plan: progress to 150 ft and introduce stairs with rail."
Occupational therapy
Weak"Pt dressed self with assistance. Pt participated well."
Stronger"Pt seen for ADL retraining targeting upper-body dressing (STG 2). Clinician trained pt in a hemi-dressing technique (affected arm first) with verbal cues for sequencing and set-up of the garment. Pt completed upper-body dressing with min assist and 3 verbal cues, down from mod assist last session. Clinician instructed pt's daughter in set-up and cueing and observed her repeat it correctly. Plan: introduce dressing aids if sequencing errors persist."
Common reasons notes look unskilled
- The same wording every day
- No numbers
- Describing the activity ("worked on balance") instead of your skill
- No link to the goal
- No change in approach after a good or bad session
A quick test before you save
Read the note as someone who wasn't there. Could they tell what you did, why it needed a therapist, how the patient responded, and what happens next? If not, add the missing piece.
Writing it faster
Specific notes take time, and that's usually the problem. One approach is to say the session out loud right after it ends and turn that into a note, which is how NoteReady works. You review and edit every note before it goes into the chart.
The examples in this article are fictional and for illustration. This isn't legal, billing, or compliance advice. Follow your facility's policies and current payer requirements.