CMS Pub. 100-02, ch. 2, § 30.4

In accordance with 42 CFR 412.27(c)(4) and 42 CFR 482.61(d), progress notes must be

recorded by the doctor of medicine or osteopathy responsible for the care of the patient as

specified in 482.12(c), by a nurse, social worker and, when appropriate, others

significantly involved in active treatment modalities. The frequency of progress notes is

determined by the condition of the patient but must be recorded at least weekly for the

first two months and at least once a month thereafter and must contain recommendations

for revisions in the treatment plan as indicated as well as precise assessment of the

patient’s progress in accordance with the original or revised treatment plan.

As outlined above in §30 of this chapter, consistent with sound clinical practice (and the

hospital conditions of participation at 482.24(c)(1)), all medical records, including

progress notes, should be legible and complete, and should be promptly signed and dated

by the person (identified by name and discipline) who is responsible for ordering,

providing, or evaluating the service furnished.