CMS SOM App. A, Tag A-1660

patient but must be recorded at least weekly for the first 2 months and at least once

a month thereafter…

Interpretive Guidelines §482.61(d)

Progress notes must be written to document the patient’s condition and the subsequent

changes during treatment. Progress notes must be recorded at least weekly for the first 2

months and at least once a month thereafter. When patients progress more rapidly or if

the patient experiences a significant change in condition, progress notes may be written

more frequently as determined by the patient’s status.

A significant change can include the need for increased observation by staff, seclusion

and restraint episodes, self-harm episodes, assaultive behaviors, elopements, decline in

medical status, falls and injuries, treatment refusal, transfer to another facility, and other

adverse events.

Survey Procedures §482.61(d)

• Review a sample of medical records. Review the progress notes in the patient's

medical record to ensure that the progress notes were recorded at least weekly

for the first 2 months and at least once a month thereafter.

• Verify that changes, variations and updates in the treatment modalities are

documented in the progress notes and the documentation shows the rationale for

any sudden change or termination of treatment. Refer to §482.61(c)(1)(v) and

§482.61(c)(2) for additional clarification on documentation of treatment.