Humans are obsessed with documenting important moments in time. Whether it’s your kid’s high school graduation or your best friend’s wedding, many of us are quick to whip out our camera or phone and snap a picture for posterity at any opportunity. It’s not just for sentimental reasons: throughout history, human beings have observed the importance of documenting events—even if it’s via a simple painting on a cave wall. And while you may not think documenting your patients’ progress throughout the duration of care—as well as at discharge—is quite the same as recording major historical developments, doing so is incredibly important in the eyes of Medicare.
But completing patient documentation requires a little more thought than taking a photo with your smartphone. In fact, some of Medicare’s documentation requirements can be downright befuddling. With that in mind, here’s everything physical therapists need to know when it comes to completing Medicare progress notes and discharge summaries.
What is a progress note?
According to Mosby’s medical dictionary, progress notes are “notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient’s condition and the treatment given or planned.” With respect to Medicare, a progress note (a.k.a. progress report) is an evaluative note that provides an update on the patient’s status at regular intervals (every 10 visits) throughout the course of care. However, a progress report does not serve the same function as a re-evaluation and, therefore, the therapist cannot bill it as such.
It’s also important to note that a Medicare progress report does not stand independent of the patient’s medical record. As John Wallace, PT, MS, WebPT Chief Business Development Officer of Revenue Cycle Management, recently explained, “It is considered in light of all the documentation that is associated within the patient’s episode of care. This would include the certified Plan of Care, the visit notes, and any other associated documents (e.g., operative reports and reports of tests).” He went on to clarify that the information from this other documentation does not need to be reproduced within the progress report; rather, the report should reference this information to demonstrate “that the patient is on track to achieve the goals established in the plan of care.”
Who can complete a progress note?
Under Medicare, a licensed physical therapist must complete progress notes for patients who are under a physical therapy plan of care. Physical therapist assistants may complete certain elements of a progress note (more on that below), but they cannot complete a Medicare progress note in its entirety.
What should a progress note include?
As I mentioned above, PTAs can supply certain required elements of a physical therapy progress note. According to CMS guidance, these elements are:
- the reporting period;
- the reporting date;
- objective reports of the patient’s subjective statements; and
- objective measurements.
That said, assistants are not permitted to make clinical judgments regarding the patient’s progress. Additionally, if a PTA assisted with the progress report, then that assistant must sign the note.
Physical therapists, on the other hand, are solely responsible for noting the following required information:
- assessment of patient improvement or progress toward each goal;
- decision regarding continuation of treatment plan; and
- any changes or additions to the patient’s therapy goals.
Progress Note Example
In this example, the patient is a 68-year-old woman with a diagnosis of right shoulder adhesive capsulitis who completed her tenth visit yesterday. She will come in for her 11th visit at the end of the week.
|Subjective: The patient reports that her resting shoulder pain has decreased from 4/10 to 1–2/10 over the first two (2) weeks of treatment. She reports being able to perform her self care and dressing with a maximum pain level of 4–5/10. She reports still being unable to reach the upper shelf in her closet or lift a gallon of milk from the refrigerator.|
Objective: The patient’s DASH score at evaluation was 60. This outcome measure was repeated yesterday, and the patient achieved a score of 35. Her PROM for flexion has advanced from 95 degrees to 140 degrees. Her external rotation has improved from 35 degrees to 60 degrees. The strength in her available range of motion remains 3+/5.
Assessment: The patient has made significant functional gains over the first 10 visits. I expect her to reach her goals of achieving a DASH score of less than 20 and being able to complete her B-ADLs and I-ADLs with pain not exceeding 2/10 within the next six (6) visits.
Plan: Will continue per the plan of care.
When should progress notes be written?
Per the Medicare Benefit Policy Manual, “The minimum progress report period shall be at least once every 10 treatment days. The day beginning the first reporting period is the first day of the episode of treatment regardless of whether the service provided on that day is an evaluation, reevaluation or treatment. Regardless of the date on which the report is actually written (and dated), the end of the progress report period is either a date chosen by the clinician or the 10th treatment day, whichever is shorter. The next treatment day begins the next reporting period.”
For example, if a new patient comes to therapy with a complaint of pain in the hip, the initial evaluation marks the beginning of the first reporting period (i.e., visit one) for that episode of care. On visit 10, the physical therapist must complete a progress note.
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You can also complete a progress report prior to the tenth visit (for example, if you know you will be unable to assess the patient personally during the tenth visit, you could complete the progress note during the ninth visit). It’s important to note, however, that the reporting period would then reset on the ninth visit, meaning the tenth visit would serve as the first session for the new 10-visit reporting period.
What is a discharge summary?
Functionally, a discharge summary (a.k.a. discharge note) is a progress note that covers the reporting period from the last progress report to the date of discharge. The discharge summary is required for each episode of outpatient therapy treatment. Per CMS, “Clinicians should consider the discharge note the last opportunity to justify the medical necessity of the entire treatment episode in case the record is reviewed.”
The Unanticipated Discharge
In the case of an unanticipated discharge (e.g., the patient stops showing up for therapy or self-discharges), the therapist may base any treatment or goal information on the previous treatment notes or the verbal reports of a PTA or other clinician. Furthermore, as this CMS document explains, “In the case of a discharge anticipated within 3 treatment days of the Progress Report, the clinician may provide objective goals which, when met, will authorize the assistant or qualified personnel to discharge the patient. In that case, the clinician should verify that the services provided prior to discharge continued to require the skills of a therapist, and services were provided or supervised by a clinician.”
Who can complete a discharge summary?
Similar to progress reports, only a licensed physical therapist may complete a Medicare discharge summary—which makes sense considering that a discharge summary is technically a progress report. But again, as with progress reports, a PTA may provide information that supports certain elements of the discharge summary (i.e., reporting period, reporting date, objective reports of the patient’s subjective statements, and objective measurements).
What should a discharge summary include?
In addition to all the elements of a regular ol’ progress report, CMS states “a Discharge Note shall include all treatment provided since the last Progress Report and indicate that the therapist reviewed the notes and agrees to the discharge.” It can also include any other pertinent information with regard to the patient’s care—at the therapist’s discretion, of course (for example, summarizing the entire episode of care or justifying services that have extended beyond the initial certification period).
Finally, the PT should review the documentation so that it “is ready for presentation to the contractor if requested.”
Discharge Summary Example
Continuing with our progress note example, we’ll say the 68-year-old patient completed her episode of care on visit 15. The discharge report covers the changes that occurred between the first progress report and the patient’s discharge.
|Subjective: The patient reports that she does not have any resting shoulder pain and that her shoulder no longer wakes her up during the night. She is able to perform her self care and dressing with a maximum pain level of 1–2/10. She is able to complete all of her required I-ADLs without significant pain or limitation. She reports that doing her home exercises in the morning and evening is helping her progress.|
Objective: Upon retesting the DASH, the patient achieved a score of 15. Her range of motion and strength are functional for her age and activity level.
Assessment: The patient has achieved the goals established in the plan of care and will be discharged with a home exercise program.
Plan: The patient will continue with her home program and will see her physician in two weeks to follow up. A separate report will be forwarded to the physician.
Documenting important moments is more than human nature; it’s absolutely essential—especially when it comes to matters of patient health. Have questions about progress notes, discharge summaries, or Medicare documentation in general? Let us know in the comment section below!