Page 203 - Medicare Benefit Policy Manual

reviewed and organized so that the required documentation is ready for presentation to
the contractor if requested.

Assistant’s Participation in the Progress Report. PTAs or OTAs may write elements of
the progress report dated between clinician reports. Reports written by assistants are not
complete progress reports. The clinician must write a progress report during each
progress report period regardless of whether the assistant writes other reports. However,
reports written by assistants are part of the record and need not be copied into the
clinicians report. Progress reports written by assistants supplement the reports of
clinicians and shall include:

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

• Date that the report was written (not required to be within the reporting period);

• 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;

• Objective reports of the patient’s subjective statements, if they are relevant. For
example, “Patient reports pain after 20 repetitions”. Or, “The patient was not feeling well
on 11/05/06 and refused to complete the treatment session.”; and

• Objective measurements (preferred) or description of changes in status relative to
each goal currently being addressed in treatment, if they occur. Note that assistants may
not make clinical judgments about why progress was or was not made, but may report the
progress objectively. For example: “increasing strength” is not an objective
measurement, but “patient ambulates 15 feet with maximum assistance” is objective.

Descriptions shall make identifiable reference to the goals in the current plan of care.
Since only long term goals are required in the plan of care, the progress report may be
used to add, change or delete short term goals. Assistants may change goals only under
the direction of a clinician. When short term goal changes are dictated to an assistant or
to qualified personnel, report the change, clinician’s name, and date. Clinicians verify
these changes by co-signatures on the report or in the clinician’s progress report. (See
section 220.1.2(C) to modify the plan for changes in long term goals).

The evaluation and plan of care are considered incorporated into the progress report, and
information in them is not required to be repeated in the report. For example, if a time
interval for the treatment is not specifically stated, it is assumed that the goals refer to the
plan of care active for the current progress report period. If a body part is not specifically
noted, it is assumed the treatment is consistent with the evaluation and plan of care.

Any consistent method of identifying the goals may be used. Preferably, the long term
goals may be numbered (1, 2, 3,) and the short term goals that relate to the long term
goals may be numbered and lettered 1.A, 1.B, etc. The identifier of a goal on the plan of