Progress note

[Sana2007]

Are you required to write Monthly Progress Notes in addition to regular visit notes at your agenciy? If yes, is it on a separate form or is it done on a regular visit note? Please let me know either way. I am reading that it is a condition of participation to have Progress notes yet any nurse I talk to from other agencies say that they do not write any progress notes. Some say that their regular visit notes are called progress notes but that's about it. Any input will be greatly appreciated. Thank you very much.

[caliotter3]

Our clinical supervisor writes a 60 day progress note that is included on the 485 that is sent forward for the MD to recertify. Field nurses do not write any kind of summaries in the course of their regular duties. I did have one agency that required input from the primary nurse for use in doing the 60 day progress note. I figure that was one way the nursing supervisor got some help with her paperwork. This is for extended care cases. Do not know how it is done in the intermittent visit side.

[Sana2007]

Thank you caliotter3. Yes, 60-day summary is written at recert and sent to the doc. I am particularly questioning about Progress Notes. I am hoping we get more responses here. But thanks for your input. I really appreciate it.

[HealthyNurse]

No, we do not write monthly progress notes. The visit notes stand as the only required documentation, in addition to any notes of communication that takes place with the patient or team members outside of a visit. I am very familiar with the COPs and I do not know of any such requirement for a monthly progress note. Where are you seeing that?

[Sana2007]

No, we do not write monthly progress notes. The visit notes stand as the only required documentation, in addition to any notes of communication that takes place with the patient or team members outside of a visit. I am very familiar with the COPs and I do not know of any such requirement for a monthly progress note. Where are you seeing that?

Thank you for your response.

The Conditions of Participation, 484.4, define a progress note as "a written notation, dated and signed by a member of the health team that summarizes facts about care furnished and the patient's response during a given period of time."

A progress note is not same as visit note or a clinical note, which is defined as "a notation of a contact with a patient that is written and dated by a member of the health team, and that describes signs and symptoms, treatment and drugs administered and the patient's reaction, and any changes in physical or emotional condition."

There is no frequency in the condition of participation but the definition for a summary report in 484.4 is, "the compilation of the pertinent factors of a patient's CLINICAL NOTES and PROGRESS NOTES that is submitted to the patient's physician", which probably means there should be at least one progress note so that it could be included in the summary.

[HealthyNurse]

Thanks for the clarification. With these definitions, we include a narrative progress note in the recert/discharge summary once per 60-day episode. There is a small narrative section where we summarize the care provided throughout the episode and the pt's response.