The Challenge

BJ Custer has led the therapy team at The Village at Orchard Ridge for 13 years, managing 12 therapists across a full continuum of care including outpatient Med B, skilled nursing, assisted living, and memory care. Documentation has always been one of the team’s biggest time demands.

Before the Ambient Documentation feature in Optima Unity with AI, a typical evaluation required 25 to 30 minutes of manual charting on top of the physical assessment itself. Therapists typed as they talked, pulling their attention away from patients and onto the screen. The quality of what they documented often depended on how rushed they were, and finishing notes after hours was a constant reality.

Key challenges included:

• Documentation burden: Manual charting requiring 25 to 30 minutes per evaluation on top of the physical assessment, reducing hands-on treatment time
• Patient engagement: Clinicians focused on their screens during sessions rather than engaging fully with patients
• Inconsistent detail:  Note quality varied based on when documentation happened, with rushed notes and after-hours charting leaving gaps
• After-hours chartings: Notes frequently completed after hours, cutting into therapist work-life balance.
• Audit exposure: Compliance risk from incomplete or rushed documentation

The Solution

As the first Optima client to purchase AI blocks for his staff, BJ led a phased rollout starting with Optima Unity to build familiarity, then rolling out Ambient Documentation to all 12 therapists across every care setting.

Optima Unity with AI captures the therapist-patient session in real time, recognizes each speaker, and automatically populates the relevant documentation fields, allowing therapists to stay engaged with patients while the documentation happens naturally in the background. Every section is reviewed and approved by the clinician before it enters the chart.

BJ identified two champions who learned the system first and served as on-site resources for the rest of the team. Rollout was smooth, adoption was strong, and within weeks the conversation shifted from troubleshooting to enthusiasm.

Results that Drive Growth

 

Improvement Over Time

• Ambient Documentation cuts manual charting from 25 to 30 minutes to 12 to 15 minutes per eval, freeing time for hands-on patient care.
• Re-evaluation and recertification time reduced by more than 50%, with AI pulling prior notes into a ready-to-use summary paragraph.
• Daily note editing is minimal — primarily removing redundancies, not correcting errors.

Efficiency Gains

• Eval documentation: AI populates the majority of evaluation fields automatically — goals, GG codes, and ICD-10 codes remain the primary manual inputs.
• Patient engagement: Clinicians stay fully present during sessions with computers set aside.
• Clinical content: Notes are more complete, more detailed, and more clinically defensible than before.
• Revenue opportunity: Time saved in evals is redirected to additional billable treatment time.
• Team adoption: The least tech-savvy therapist became the highest AI adopter, familiar with the format from prior dictation experience.

Business Impact

In fewer than three months, Optima Unity with AI transformed how BJ’s team documents, engages with patients, and manages their workday. Eval documentation time dropped by half. Clinical content improved dramatically. After-hours charting is no longer a constant. Therapist satisfaction has remained high since rollout, with full team retention and no sustained complaints.

BJ is already planning the next phase: using the time savings to drive measurable productivity improvements and increase billable treatment time per evaluation. The best results are still ahead.