Please note that this article contains information that is only relevant to American clinics.
A recent article from Gawenda Seminars and Consulting discussed progress reports and asked an extremely relevant question: what are the required elements? We know that the requirements vary from patient to patient, and from payor to payor, but what are the standard components that no progress report can considered complete without? Let’s examine the 7 things your progress reports must include.
Progress reports are an essential component of a patient’s recovery process. They help ensure that the patients are on the right track, and that the treatment they’re receiving is having a positive affect on them. Generally speaking, progress reports have certain requirements that are the same across the board, and they can have certain requirements that are unique to individual payors—it’s up to you to get in touch with the payors and find out exactly what’s required by them.
The Centers for Medicare and Medicaid Services (CMS) provides some relatively standard requirement for progress reports. For example, their guidelines clearly state that a clinician is required to report once every 10 treatment days. However, it’s important to note that if a patient had two visits by the same type of clinician (i.e. a speech therapist) in the same day, it still counts as one treatment day.
Now that we know when to complete a progress report, let’s look at the required 7 of the things that your progress reports should include for individuals receiving outpatient therapy through the Medicare program:
1) Include the start and end date of the reporting period, as well as the date that the report was written
2) Objective reports on the patient’s subjective statements, if relevant
3) Objective measurements or description of changes in status relative to the goals that the therapy is trying to meet
4) There’s been an improvement, or lack of, towards the goal
5) There are plans to continue the treatment
6) Changes to either the long or the short term goals
7) The signature and professional identification (i.e. NPI #) of the individual who performed the treatment
All the same, Rick reminded us to “check with each insurance carrier to see if they have different requirements as well as time frames for how often a progress report may be required.”