Physical therapist assistants (PTA) or occupational therapist assistants (OTA)may write elements of progress notes dated between clinician reports, but a clinician must ultimately write the progress notes.
Medicare Progress Note Requirements
Learn the key Medicare Progress Note Requirements for tracking patient progress, ensuring service justification, regulatory compliance, and timely payment.
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Commonly asked questions
Yes, progress notes are required and should be written and signed by the therapist providing the services or by qualified personnel under the physician's direct supervision.
Therapy progress notes must meet specific requirements to ensure compliance with regulatory standards and effective documentation of patient care. Key elements include the beginning and end dates of the reporting period, the date the report was written, and objective measurements that demonstrate patient progress. Additionally, they should detail any changes in the patient's status relative to their treatment goals, provide an assessment of improvement, outline plans for ongoing treatment, and include any updates to goals or care plans. Finally, the note must be signed by the clinician with their credentials to validate the documentation.
