Home Health & Hospice

Define Your Agency?s Version of a Progress Note

Homecare Insider, May 10, 2010

Compliance is not easy in home health care.  The rules seldom tell you how you should do something.  Add in the fact that confusion and misinformation surround every issue.  Consider this question from a homecare nurse. 

If progress notes are required, then how come our agency has never been cited?  Through many years of surveys, we’ve developed a routine that includes a 60-day summary on the plan of care, a visit note for every visit, and a monthly case conference note, which incorporates a summary and is signed by each discipline.

A progress note, as defined in the Conditions of Participation, §484.2, is a written notation that summarizes the facts about the care furnished and the patient’s response during a given period of time.  Nurses, therapists, therapy assistants, and social workers must document progress notes.  A progress note is not a visit note but rather a summary. 

The regulations do not define a format for the progress note so an agency must decide how to structure this documentation.  Even though this agency does not seem to know about the progress notes, it appears to be demonstrating compliance with the requirements.  The case conference note, signed by all participating disciplines, most likely provides a summary of the care and the patient’s response during that month, the same content of a progress note.  It would be wise for this agency to revise its policies to identify the monthly case conference note as its progress note and educate staff about this requirement.  These actions would avoid a citation in the event a surveyor was to ask a staff member how the agency complies with the progress note requirement.

A monthly case conference note is only one way to comply with this requirement.  An agency can use a separate form, write a progress note paragraph as part of a visit note, or establish some other method.  Bottom line:  Understand the intent of the regulation and then know how your agency meets the requirements. 

Want to learn more about important components of documentation.  Check out PPS Documentation:  The Supporting Cast, an educational DVD.  Check it out at — http://www.beaconhealth.org/cgi-bin/ccp51/cp-app.cgi?pg=prod&ref=22-480-00.