Recording Progress

30.4 - Recording Progress (Rev. 253, Issued: 12- 14-18, Effective: 01-16-19, Implementation: 01- 16-19) 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.