Creating a Progress Note

Progress Notes must be completed at every 10th visit according to Medicare Guidelines. The system will prompt a PN or DS task once the 10th visit is up or the plan of care is up. A user may complete a Progress Note at any time by clicking on the words Progress Note within he patient's case documentation page.

Select the PN or DS task either in the Work Queue or within the Documentation page of the patient's case.

Select either Request more visits in a Progress Note and continue Treatment OR Discharge the Patient.

Once the request has been selected, the system will generate the Progress Note.
Enter any Comments (optional)
Subjective - Enter Chief Complaints
Problems/Goals List - Update the Current for any Objective findings. Users may add new measurements by selecting Add New Measurement

Users may un-check the flag if the goal is discontinued. If the patient regresses from a goal that has been completed, users can pull the goal back by selecting the flag in the Discontinued Goals section.
Update the Goal % on the Problems/Goals
Assessment - Select the Rehab Potential and enter the Therapist Assessment

Treatment Plan - Add/remove any CPT codes listed in the treatment plan
Plan of Care Status, Frequency and Duration, Recommendations - Select either continue with 7 remaining visits and update the frequency and duration if needed. If there are 0 weeks remaining, users will need to select Update the Plan of Care, I need 0 visits in addition to the 7 remaining and _ more weeks.

Placing patient on hold - Users may place the case on hold by selecting Place patient on hold. Select the time frame for the case to be on hold. **Please Note, placing the case on hold will prevent users from documenting on future notes until the hold has been released. Please refer to Progress Note Placing Case on Hold tutorial**.

Additional Recommendations - Enter if any recommendations
Sign and Submit.

**Note: If the note is not yet complete, click the Save Changes button and return later to finish it.