Documentation is extremely important because it serves as a record of patient care, including report of patient status, physical therapy management, and the outcome of physical therapy. Each insurance has different requirements for what must be included in specifically in progress report documentation.

Here are some highlights that you should be aware of every time you are completing a progress report:

Medicare:

  • Date that the report was written

  • Date of the beginning and end of the reporting period that this report refers to

  • Objective reports of the patient’s subjective statements, if they are relevant

  • Objective measurements (preferred) or description of changes in status relative to each goal currently being addressed in treatment, if they occur

  • Assessment of improvement, extent of progress (or lack thereof) toward each goal

  • Plans for continuing treatment, reference to additional evaluation results, and/or treatment plan revisions should be documented in the clinician’s progress report

  • Changes to long or short term goals, discharge or an updated plan of care that is sent to the physician for certification of the next interval of treatment

  • Signature, and professional identification, or for dictated documentation, the identification of the qualified professional who wrote the report and the date on which it was dictated

Blue Cross Blue Shield:

  • Time period covered by the report

  • Start of Care Date

  • Medical and therapy treatment diagnoses

  • Statement of the individual’s functional level at the beginning of the progress report period

  • Statement of the individual’s current status as compared to evaluation baseline data and the prior progress report, including objective measures of the individual’s function that relate to the treatment goals

  • Changes in prognosis and why

  • Changes in plan of care and why

  • Changes in goals and why

  • Consultations with other professionals or coordination of services, if applicable

  • Signature and title of qualified professional responsible for the therapy services

Have other main payers in your payer mix that you want to learn more about requirements for? Contact us inquiries@lincolnrs.com with questions.