US · guidance
CMS SOM App. A, Tag A-1661
§482.61(d) …and must contain recommendations for revisions in the treatment plan
as indicated…
Interpretive Guidelines §482.61(d)
Documentation of treatment progress should identify the objective efforts the patient is
making toward accomplishing the target goal of the individualized treatment plan, and
they must contain recommendation(s) for updating the treatment plan as indicated.
When updating or revising the treatment plan, documentation indicates the reason for the
revisions and reflects the acuity of the illness of the patient. The acuity of the illness of
the patient and the length of hospital admission or treatment for outpatients, determines
the expected frequency of the treatment plan revision(s). If the patient is more acutely ill,
the surveyor should see an increase in the frequency of documentation describing the
patient’s illness, treatment, and interventions, and the patient’s progress and changes to
the treatment plan, if appropriate.
Survey Procedures §482.61(d)
• Review the sample of medical records and verify that changes in the patient’s
condition are reflected in the progress notes and recommendations for revisions
to the current treatment plan are included.
History
Rev. 238; Issued: 03-20-26; Effective: 09-05-25; Implantation: 09-05-25
Provenance
- Source
- cms.gov
- Retrieved
- 2026-07-22
- Edition
- som-2026-07-22
- Content hash
66a366ad4f9c4c89818bdf0d21b4b96baa5189e7121827bf9247a2aaa40e8272
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