CMS Pub. 100-11, ch. 8, § 30.7

Progress notes detail the care delivered by practitioners performing within their scope of

practice as they manage day-to-day participant encounters or follow up on care provided

during previous encounters. Progress notes may be formatted as the traditional “SOAPE”

note commonly used by many clinical professionals, a narrative description of care

rendered, or other format designed for narrative text entry in an electronic medical

record. The progress note format is prescribed in the PACE organization’s policy and

procedures for medical record documentation.

The progress note not only gives sufficient information to enable other providers to know

what care has been given, but also explains the details of the encounter and the clinical

judgment applied so that subsequent care enhances therapy without redundancy or

contravention. For example, a progress note would refer to subjective information

reported by the participant (e.g., complaints, concerns, effectiveness of ongoing therapy,

etc.), objective findings noted by the provider (e.g., vital signs, weight, examination of

body systems, random blood sugar test, etc.), the assessment of the findings (e.g.,

diagnosis, presumptive condition, etc.), the therapeutic approach taken (e.g., medication,

procedure, lifestyle activity, self-management strategy, etc.), and a discussion about how

the participant was educated about the treatment approach and agreement/disagreement

with the treatment planned (e.g., demonstration of self-management technique, discussion

about disease stages, explanation of medication side effects, etc.). A narrative progress

note may document an exchange between providers (e.g., documentation of a discussion

with the hospitalist managing the case of a hospitalized participant, summary of a

meeting with a nursing facility’s care planning team for a participant placed in a skilled

nursing facility, description of a home care coordinator’s visit to the contracted home

care facility to review contractor records, etc.) or between IDT members and the

participant’s family or other caregivers (e.g., discussion of a proposed change in a

participant’s care plan, discussion of a grievance filed by the participant and/or family,

etc.). Consider the following three examples.

In example 1, the physician or mid-level practitioner (nurse practitioner or physician

assistant) documents in a medical “SOAPE” note the subjective complaints, objective

measurement of vital signs and a body system-by-system assessment, existing or new

diagnoses, therapeutics, orders for diagnostic tests or specialty services, and participant

education for a participant’s chronic care visit to manage multiple co-morbid chronic

conditions.

In example 2, the registered nurse documents in the nursing “SOAPE” notes subjective

complaints, vital signs, the wound appearance (depth, width, color, drainage, degree of

granulation, warmth/coolness, etc.), nursing diagnosis, and sterile or non-sterile technique

used when packing and dressing a decubitus ulcer during a skilled nursing visit for

wound care.

In example 3, the physical therapist documents in the physical therapy narrative progress

note a participant’s self-report of walker use in the home, results of range of motion and

strength measurement, and performance of strength-building exercises during a therapy

session. Progress notes summarize the chronological clinical care and underlying clinical

judgment applied by the individual clinician.