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.
Progress Notes
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.
Never miss another progress note. See how WebPT simplifies Medicare documentation with built-in alerts and templates.
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.
Discharge Summaries
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!
FAQs
How do you write a discharge summary for PT? ›
- Reason for hospitalization: description of the patient's primary presenting condition; and/or. ...
- Significant findings: ...
- Procedures and treatment provided: ...
- Patient's discharge condition: ...
- Patient and family instructions (as appropriate): ...
- Attending physician's signature:
A discharge summary should comment if the patient/client stops coming to therapy against recommendation of the physical therapist. If the patient/client is discharged prior to achievement of goals and outcomes, there should be documentation as to the status of the patient/client and the reason for discontinuation.
How do you write a therapy progress note? ›- Be Clear and Concise. Therapy notes should be straight to the point but contain enough information to give others a clear picture of what transpired. ...
- Remain Professional. ...
- Write for Everyone. ...
- Use SOAP. ...
- Focus on Progress and Adjust as Necessary. ...
- Record Better Notes with Sunwave Health.
- Self-report of the patient.
- Details of the specific intervention provided.
- Equipment used.
- Changes in patient status.
- Complications or adverse reactions.
- Factors that change the intervention.
- Progression towards stated goals.
- Communication with other providers of care, the patient and their family.
Introduction. Hospital discharge summaries serve as the primary documents communicating a patient's care plan to the post-hospital care team. 1, 2. Often, the discharge summary is the only form of communication that accompanies the patient to the next setting of care.
What are 4 things that are required for a patient's successful discharge? ›...
Selecting the right facility
- Too often choosing a facility can be a source of stress for families. ...
- Ask for help. ...
- Focus on quality of care.
Progress notes can be written by hand or typed. Write down events in the order in which they happened. Include both positive and negative occurrences, and anything out of the ordinary. Record errors made by caregivers - even your own errors!.
What is the most recommended format for documenting progress notes? ›The SOAP (Subjective, Objective, Assessment, and Plan) note is probably the most popular format of progress note and is used in almost all medical settings.
What should be written in progress notes? ›Progress notes record the date, location, duration, and services provided, and include a brief narrative. Documentation should substantiate the duration and frequency of service delivery. The narrative should describe the following elements: Client's symptoms/behaviors.
What writing format do physical therapists use? ›In the biomedical sciences and allied health fields, popular citation styles include APA Style (American Psychological Association) and AMA Style (American Medical Association).
What do therapists write in their notes? ›
Clinicians often use a template for their progress notes, such as the DAP or SOAP format. Notes in the DAP—data, assessment, and plan—format typically include data about the individual and their presentation in the session, the therapist's assessment of the issues and progress, and a plan for future sessions.
What is SOAP format for physical therapy? ›SOAP is an acronym that's short for Subjective, Objective, Assessment, and Plan. A physical therapy SOAP note is entered into a patient's medical record to chronicle each episode of care, share information with other healthcare providers, and inform the clinical reasoning process.
What are the three C's in discharge planning? ›Nurses care for their patients from admittance to discharge, which provides ample opportunity to foster great patient experiences. As a company who's focused on nursing and hourly rounding, Nobl believes great patient care comes down to three key nursing factors: collaboration, communication, and compliance.
What are the 10 steps to discharge planning? ›- The 10 steps of discharge planning. ...
- Start planning before or on admission. ...
- Identify whether the patient has simple or complex needs. ...
- Develop a clinical management plan within 24 hours of admission. ...
- Coordinate the discharge or transfer process.
Discharge summaries should be completed within 3-7 days after the patient is discharged. Completed means that the summary has been dictated and/or transcribed and electronically signed.
Where can I get a discharge summary? ›A request can be made to any Patient Service Centre or directly with the Medical Records Office if the patient has been discharged.
Is medical abstract same as discharge summary? ›“Clinical Summary” – a term used when the patient is still within the hospital and prior to discharge. “Medical Abstract/ Discharge Summary” – a term used when the patient has already been discharged.
Does a discharge summary need a physical exam? ›A: According to coding guidelines, discharge services should include a final examination when appropriate, so the general consensus is that you do need to perform one.
What three 3 elements should be part of the discharge summary form? ›As a minimum, the Discharge Summary should contain the following elements: Patient Identification (full name, date of birth, unit record number and address) Admission and discharge dates. Discharging Medical Officer's name and clinical unit.
What is discharge checklist? ›This checklist will help facilitate a safe, smooth and seamless transition from hospital/hospice care for the dying person who chooses to be cared for at home. • Hospital/hospice staff must prioritise the discharge as URGENT to minimise any potential.
Who is responsible for discharge summary? ›
A discharge summary will have been written by the doctor who was responsible for your care while you were in hospital. This is so your GP knows what tests and treatment you've had.
What does a good progress note look like? ›Write down what was heard or seen or witnessed, what caused it, who initiated it. Concise - Use fewer words to convey the message. Relevant - Get to the point quickly. Well written - Sentence structure, spelling, and legible handwriting is important.
What are the four sections of a progress note? ›The 4 headings of a SOAP note are Subjective, Objective, Assessment and Plan.
How do you write a progress report summary? ›- Think of it as a Q&A. ...
- Use simple and straightforward language. ...
- Avoid using the passive voice where possible. ...
- Be specific. ...
- Explain jargon if needed. ...
- Spell out acronyms when they first occur in the document. ...
- Stick to facts. ...
- Use graphics to supplement the text.
When taking mental health progress notes, it's important to avoid using any names or identifiers that could reveal the identity of any third party unless necessary. This includes names of family members, employers and other individuals who may come up when discussing the client's mental health.
What are the 7 legal requirements of progress notes? ›- Be clear, legible, concise, contemporaneous, progressive and accurate.
- Include information about assessments, action taken, outcomes, reassessment processes (if necessary), risks, complications and changes.
- Meet all necessary medico-legal requirements for documentation.
A Progress Note template can be used in the medical field by doctors to write down patient information regarding their condition.
How many sentences should a progress note be? ›In order for your notes to be effective (particularly when it comes to coordination of care), this information needs to be accurate. Subjective review of the patient: The subjective section of a progress note should be around 3-5 sentences long.
What is a progress report template? ›The project progress report template is a key line of communication between the project manager and the project's stakeholders. It is compiled by the project manager, or in some cases, an assistant to the project manager.
Can PT write scripts? ›But for most PT patients, no, a physical therapist is not authorized to write you a prescription.
How do you document patient education in physical therapy? ›
- include detailed instructions provided to the patient;
- note the patient's ability to learn and apply the instructions;
- demonstrate the skilled nature of the service; and.
- reflect the service's relationship to the POC.
Objective – The objective section contains factual information. Such objective details may include things like a diagnosis, vital signs or symptoms, the client's appearance, orientation, behaviors, mood or affect. For example, client is oriented x4 (person, place, time, situation), client appears disheveled.
What is the difference between progress notes and psychotherapy notes? ›The Difference Between Therapy Notes and Progress Notes
Therapy notes are private records meant to help therapists remember patient encounters. Progress notes, on the other hand, record information relevant to the patient's treatment and response to treatment.
- SOAP notes: SOAP notes are the most common type, containing four separate types of information in four distinct rows: ...
- BIRP notes: BIRP notes contain information similar to SOAP notes, just reorganized to emphasize behaviour and concrete interventions: ...
- DAP notes:
- Find the appropriate time to write SOAP notes.
- Maintain a professional voice.
- Avoid overly wordy phrasing.
- Avoid biased overly positive or negative phrasing.
- Be specific and concise.
- Avoid overly subjective statement without evidence.
- Avoid pronoun confusion.
- Be accurate but nonjudgmental.
- Consider how the patient is represented: avoid using words like “good” or “bad” or any other words that suggest moral judgments.
- Avoid using tentative language such as “may” or “seems”
- Avoid using absolutes such as “always” and “never”
- Write legibly.
SOAP stands for Subjective, Objective, Assessment, and Plan. Each letter refers to one of four sections in the document you will create with your notes.
How do you write a patient summary report? ›A good medical summary will include two components: 1) log of all medications and 2) record of past and present medical conditions. Information covered in these components will include: Contact information for doctors, pharmacy, therapists, dentist – anyone involved in their medical care. Current diagnosis.
How do you write a discharge letter to a patient? ›As we discussed, I find it necessary to inform you that I will no longer be able to serve as your doctor as of (date at least 30 days from date of letter). The primary difficulty has been (indicate general reason, e.g., your failure to cooperate with the medical care plan, your behavior toward my staff, etc.).
What should a patient summary include? ›Clinical Summary – An after-visit summary that provides a patient with relevant and actionable information and instructions containing the patient name, provider's office contact information, date and location of visit, an updated medication list, updated vitals, reason(s) for visit, procedures and other instructions ...
What should be included in a report summary? ›
It should restate the purpose of the report, highlight the major points of the report, and describe any results, conclusions, or recommendations from the report. It should include enough information so the reader can understand what is discussed in the full report, without having to read it.
What is a patient summary report? ›Your Summary Care Record is a short summary of your GP medical records. It tells other health and care staff who care for you about the medicines you take and your allergies.
What is an example of a letter of discharge? ›Dear Mr./Ms./Mrs.: I am writing to formally discharge you as a patient from my medical practice. Between now and (date one month from today), we will provide you emergency care as needed. This should allow you amply time to find another practice to provide your podiatric care. We do not like to discharge patients.
What information is on a discharge letter? ›A hospital discharge letter is a brief medical summary of your hospital admission and the treatment you received whilst in hospital.It is usually written by one of the ward doctors.