Click here to access our customizable physical therapy progress note template. Click “copy” to create a word doc or PDF to customize to your practice needs.
What is a Progress Note?
A physical therapy progress note template updates a prescribing physician on their patient’s current status towards their goals. Per CMS guidelines, ‘’The progress report provides justification for the medical necessity of treatment.”
How often is a Progress Note required?
According to the CMS guidelines, “The minimum progress report period shall be at least once every 10 treatment days.”
Do I need a progress note for private insurance?
Maybe. Many insurance companies will require a progress note in order to authorize more sessions. Generally speaking, the insurance companies want to ensure the patient is making progress before they authorize more sessions or visits.
Do I need to create two notes for this visit/ date of service?
No. Because it follows the standard SOAP formula for daily documentation, a progress note will take the place of the daily note.
Can you bill for a progress note?
No. Medicare considers the progress report to simply be a "good documentation practice, and therefore it would not be payable" under Medicare guidelines. There is no CPT code for a progress note. IMPORTANT: Do not confuse progress notes with re-evaluations. They are separate processes.
Key Components of a Progress Note
Writing an effective progress note is a balance of CMS requirements and keeping the note concise enough for a physician to read quickly. Be mindful that the physician may have less than a minute to review your notes. Be clear and to the point.
On the other hand the note should comply with CMS requirements:
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.
Let’s review the key components of a progress note.
Time Frame
Be sure to record your start and end date/time of the reporting period. The reporting period is a reflection of the segment within the time of the certification period. It may be from the initial evaluation date to this current progress note date. It may be from this progress note date to another progress note date. The therapist needs to identify what period of time the data in the progress note is referring to.
Patient Subjective
The therapists should give a brief statement on how the patient feels and how they've progressed over this period. As with a regular treatment/soap note, comment on the patient's subjective statements, “the patient reports three out of 10 pain in his shoulder but feels that he's been getting stronger overall since starting PT. He is now able to reach head level without sharp pain in his shoulder.”
Objective Information
Objective data may include elements such as range of motion, strength, special tests, etc… This can include other reporting tools like the Oswestry or Quick Dash. It is important to note that a therapist should not perform or include an overwhelming amount of special tests in a progress note. That would make it difficult for the physician to locate relevant findings and comparisons. Include the most relevant tests and indicate whether or not it's a positive or negative test. Range of motion and any objective measures should include a comparison to their previous test date. This will serve as an effective way to document progression or even regression.
“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. ” It's also helpful to present your data in a grid format especially for range of motion and strength measurements.
Range of Motion
| MMT R | MMT L | AROM L | PROM L | AROM R | PROM R |
Knee Flexion | | | | | | |
Knee Extension | | | | | | |
Hip Flexion | | | | | | |
Hip Extension | | | | | | |
Hip Abduction | | | | | | |
Ankle Dorsiflexion | | | | | | |
Ankle Plantarflexion | | | | | | |
Assessment
Statement on improvements
Medicare requires providing a statement on improvements and even changes to their goals. In this section of the progress note the physician will want to read your overall thoughts of the patient's progress towards their goals and how you expect to advance their treatment. A progress note should comment on the improvements or lack of improvements towards the patient stated goals. These comments should reflect your assessment as to why the patient needs further skilled treatment.
Progress to goal
The therapist will need to remark on the status of and any progress to the long term or short term goals that you've set with the patient. The therapists may update or modify goals, “the patient has achieved all short term goals and is progressing well towards long term goals. He lacks full range of motion into shoulder flexion, but this should improve as we continue with strengthening in the next phase of PT.”
Plan for continuation of care
Outline the plan for the patient's ongoing treatment. Here the therapist can decide if they are going to continue the original plan or if it's time to make changes to the plan of care. Your plan of care should reflect your objective findings and be aligned with your assignment.
Do we need to change treatment? How often is the patient being seen? Add or remove goals? Include details such as proposed interventions, exercises, modalities, frequency of sessions, and anticipated treatment duration.
“We will focus on eccentric strengthening as well as motor control for better scapular mechanics. Continue to progress with strengthening of the shoulder including stabilization techniques and PNF manual resistance. Recommended continuation of therapy 2 times a week, for three weeks to achieve goals”
Signature and Date
Sign and date the note! Be sure to legibly include your professional identification and credentials.
Progress Note Summary
There is a lot of detail that could and should go into a progress note. To simplify, your progress note should answer these questions;
Who is the patient?
What is the reporting period?
What is the chief complaint?
Have we made progress towards our goals?
What subjective and objective findings tell us we have made progress?
Is more rehab treatment necessary for the patient to reach their goals?
What potential does that patient have to rehab therapy?
What is the rehab plan to reach those goals?
While progress notes are required by CMS and most private insurance companies, progress notes are great documentation practice for all therapists. Even if you are a self-pay or cash practice progress notes can provide important milestones to keep the therapist and the patient motivated toward their goals.
Physical Therapy Progress Note Template
Click here to access our customizable physical therapy progress note template. Click “copy” to create a word doc or PDF to customize to your practice needs.
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