From therapy note sample to leadership-ready risk report.
A controlled, facility-facing pre-audit workflow that complements the EHR. Official documentation stays in the facility system and remains the source of truth; SMEG provides risk visibility and human-reviewed findings.
Three stages. Source-backed checks. Human review before conclusions.
Explore the workflow with synthetic notes.
- • Public demonstration uses SMEG-supplied synthetic information only
- • No public upload or self-service patient-record intake
- • Facility-approved export workflow may be scoped after authorization
- • Direct EHR integrations are planned capabilities, not live integrations
Source-aware screening with clinician-led validation.
- • CMS Pub. 100-02 Ch. 8 §30 (SNF Part A skilled care)
- • CMS Pub. 100-02 Ch. 15 §220–§230 (outpatient / Part B)
- • CMS Therapy Services — Medicare Part B — CY2026 KX thresholds
- • PDPM PT/OT/SLP component logic
- • MDS 3.0 Section O alignment
- • Documentation-integrity and review-trail indicators
Risk grade, patterns, and action priorities.
- • Documentation score per reviewed note (see how it works)
- • Plain-language issues plus source context where applicable
- • Suggested documentation improvement language for clinician review
- • Checks that were not evaluated, with missing context explained
- • Qualified reviewer decisions and QA release before facility findings
Qualified review with clear professional boundaries.
For a future pilot, discipline-appropriate reviewers and a QA owner must be agreed in advance. Rules propose; reviewers confirm, modify, dismiss, or escalate; QA releases. This is not medical-necessity, billing, MDS, compliance, or payer approval.
- • PT / OT / SLP documentation-risk themes
- • Skilled-need and goal-support language
- • Payer- and setting-aware Part A, Part B, PDPM/MDS, Section O, and supervision context
- • High-priority findings for clinician-led validation
- • Compliance, legal, billing, and payer-policy decisions
- • MDS coding and official reimbursement decisions
- • Official EHR documentation and clinical decision-making
- • Final approval of any internal corrective action
The core source areas SMEG checks.
Findings are mapped to source-backed documentation-risk concepts where applicable, plus clearly labeled best-practice/documentation-integrity indicators.
SNF Part A skilled care — documentation
Section 30.2.2.1 asks for a rationale for the skilled service and the patient’s response during the current visit. CMS names “Patient tolerated treatment well” and “Continue with POC” as insufficient on their own.
View source ↗Outpatient therapy services — coverage and documentation
Chapter 15 addresses outpatient therapy coverage, plans of care, documentation, and practice conditions. These Part B rules are not a universal checklist for Medicare Part A SNF stays.
View source ↗CY2026 KX modifier thresholds
For CY2026, Medicare's KX modifier threshold is $2,480 for PT and SLP services combined and a separate $2,480 for OT services. CMS also retains a targeted medical review threshold of $3,000; review above that level is targeted, not automatic. SMEG flags KX/threshold documentation risk for review.
View source ↗Therapy component classification
PDPM classifies payment for covered Medicare Part A SNF stays. It does not establish coverage or supply Part B certification and progress-report rules. A note excerpt alone cannot validate an MDS assessment.
View source ↗Section O — Special treatments & therapy minutes
MDS/PDPM-related documentation-risk checks are part of SMEG’s review logic, with payer/facility-specific review still requiring human validation.
View source ↗Signatures and late entries
Services should be documented when provided, and late entries must be identified with their date and author. CMS sets no day limit; SMEG’s 2-day signature check is an internal review prompt.
View source ↗A sidecar review, not an EHR replacement.
Therapists keep documenting in the facility-approved EHR. SMEG provides a sidecar review report for leadership, DOR, compliance, and revenue-cycle discussion.
For the therapist
Document in the approved EHR. The demonstration uses SMEG-supplied synthetic information. Actual records require written facility authorization and complete applicable BAA, vendor, security, access, intake, retention, and deletion approvals before an approved intake path is used.
SMEG suggests what type of clinical support may be missing, where the gap appears, and why a clinician/compliance reviewer may want to address it.
For therapy and facility leadership
Proposed pilot report: facility summary, discipline patterns, documentation themes, reviewer decisions, and next steps. The public report is an editorial synthetic example, not a working multi-building dashboard.
Review trail: findings, reviewer notes, and action priorities can be tracked for internal quality improvement and documentation follow-up.
Start with a synthetic demonstration.
Start with SMEG-supplied synthetic information. A real-record review is separately scoped only after the facility’s full authorization, security, vendor, intake, retention, deletion, and human-validation controls are approved.