CMS SOM App. A, Tag A-1655

Progress notes must be recorded by the

physician(s), psychologists, or other licensed practitioner(s) responsible for the care

of the patient as specified in §482.12(c); nurse, social worker and, when appropriate,

others significantly involved in active treatment modalities.

Interpretive Guidelines §482.61(d)

Progress notes must be recorded by the doctor of medicine or osteopathy, psychologists,

or other licensed practitioners responsible for the care of the patient as specified in

§482.12(c), nurse, social worker and, when appropriate, others significantly involved in

active treatment modalities.

• Doctor of medicine or osteopathy (MD/DO): Progress notes must be recorded by

the physician(s), psychologist(s), or other licensed practitioner(s) responsible for

the care of the patients as specified in §482.12(c).

• Nurses: Nursing progress notes documentation must be current and should give a

clear picture of the patient’s needs and the patient’s response to nursing

interventions. Nursing progress notes must follow hospital policy and nationally

recognized standards of practice.

• Social workers: Those who are significantly involved in active treatment

modalities/interventions must provide current documentation of every therapeutic

engagement and intervention, and the patient’s response to the treatment. Social

work progress notes must follow hospital policy and nationally recognized

standards of practice.

• Staff from other disciplines, e.g., rehabilitative therapy, recreational therapy,

group therapy, and psychology: Those who are significantly involved in active

treatment modalities/interventions must provide current documentation of every

therapeutic engagement and intervention, and the patient’s response to the

treatment. Progress notes documented by individual disciplines must follow

hospital policy and nationally recognized standards of practice.

Survey Procedures §482.61(d)

• Verify that Medicare patients are under the care of a MD/DO, psychologist(s), or

other licensed practitioners responsible for the care of the patient.

Review a sample of medical records and verify that physicians, nurses, social

workers, and other care providers who are significantly involved in active

treatment modalities/interventions are documenting the patient’s progress toward

achieving the individualized treatment goals.

• Do the progress notes provide a clear picture of the patient’s progress or lack

thereof? Do the physicians, nurses, social workers, and other care providers

make recommendations for further care?