Clinical Documentation
Notes Finished During the Visit
Capture the encounter the way you already work and get a structured, payer-ready note back before the patient leaves the room.
What it does
Less time in the record, more in the room
Each of these removes a step you currently do by hand: transcribing the encounter, formatting the note, and checking it against the code you are billing.
Voice-first capture
Dictate or record the encounter. Speech recognition is tuned for O&P terminology like ischial containment, dynamic response, and voluntary closing, and it separates practitioner speech from the patient's.
L-code aware templates
Separate templates for evaluations, fittings, follow-ups, and repairs, each carrying the elements its billing code requires. Add your practice's own fields, or share a template across the team.
Prompts for what's missing
When a note is short an element the code needs, such as a K-level or a functional justification, you hear about it while you are still in the note rather than after a denial.
Three ways in
However you document now
Dictate, record, or type. The finished note comes out the same either way.
Dictate
Speak the encounter and let the note assemble as you go.
Ambient
Record the visit and have the clinical detail pulled out of the conversation.
Type
Work in a structured form when you would rather write than talk.
How it works
From encounter to completed note
The draft is ready inside the appointment, so the review happens while the encounter is still fresh. The system drafts; the clinician signs off.
- 01
Capture the encounter
Dictate, type, or record ambiently. Voice commands move between sections hands-free.
- 02
Structure the note
Your input becomes a formatted clinical note in the template for that encounter type.
- 03
Review and adjust
You read it, change what you want, and stay the author of the record.
- 04
Send to your EHR
Copy the finished note into your practice management system in one action.
Testimonials
What O&P teams say
“I absolutely am obsessed with O&P Assist. We have received no findings from insurances requesting audits on our Practitioner notes. O&P Assist gives exactly what Medicare is asking for when it comes t...”
“I love everything about this program! I can not tell you how much pressure it has taken from us as admin, and how much quicker it makes our job. As far as I'm concerned, this is a Godsend :-)”
“O&P assist is a game-changer for our practice and support has been outstanding!”
“THANK YOU!! What a fantastic tool this is for the orthotic and prosthetic field!”
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See O&P Assist in action
See how O&P Assist fits your clinical and reimbursement workflow.