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Can Assistants Write Progress Reports

by • May 7, 2018 • 6 Comments

Last week, I published “Who Writes Progress Reports Under Medicare Part B” and as you can imagine, had lots of follow up questions and comments. Some of the questions received were:

1. Can a physical therapist assistant (PTA) or occupational therapy assistant (OTA) see the Medicare patient the same day the physical therapist (PT) or occupational therapist (OT) also sees the patient and will write the progress report?

2. Can a PTA or OTA see the Medicare beneficiary for a follow-up therapy visit, collect the subjective information and objective data and include that information in their daily note?

3. Can a PTA or OTA write the entire progress report on a Medicare beneficiary and just have the PT or OT cosign their note?

4. What components of a progress report can the PTA or OTA write for a Medicare outpatient?

5. What are the required components of a progress report written by a PT or OT for a Medicare outpatient?

6. Can the PT or OT use the information the PTA or OTA gathered and re-write that information into their progress report?

7. Does the PT or OT have to re-write the information that the PTA or OTA gathered and documented in their note or can they just refer to that information in their progress report and document the other components that the PT or OT must complete for a Medicare progress report?

In this article, I will answer these 7 questions and provide the resource for my answers. Lets begin!

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6 thoughts on “Can Assistants Write Progress Reports”

  1. Heather Margulis says:

    this is great information, thank you!

    Can you provide similar information detailing the specifics of the regulations on PTA/COTA to write progress notes under Medicare Part A?

    1. Rick Gawenda says:

      Thank you for the comment. CMS does not provide this type of guidance for SNF Part A therapy services paid under RUG levels. You would then need to defer to your state practice act.

  2. Colter Sullivan says:

    Thank you for this information! Is it wrong for a PTA or COTAs signature to accompany the PT/OT’s signature on a Medicare Progress Note? Or is it okay as long as their involvement in writing the note follows guidelines? Thank you!

    1. Rick Gawenda says:

      Assistants can’t write the required Progress Report under Medicare Part B so there should be no need for them to sign.

  3. mary daugherty says:

    Can OTA/PTA write the discharge summaries for inpatient/acute care patients? Since it is the doctor that is discharging the patient from the hospital, and a discharge summary is needed for OT/PT services that took place—could the assistants complete the d/c summary with a co-signature of the therapist [OT or PT]?

    1. Rick Gawenda says:

      You would need to check your state practice act regarding what a PTA and OTA can and can’t do. many state practice acts prohibit a PTA or OTA from writing the DC summary. Typically, in the inpatient acute care setting, the last treatment note tells the status of the patient. If your practice act requires a DC summary, it most likely will have to be done by the PT or OT.

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