Can Assistants Write Progress Reports

May 7, 2018
Rick Gawenda

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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  1. 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. 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.

      1. Hi my company has just transferred to a new company, they are now asking that COTA’s do progress notes, recertifications and d/c summaries. What is the laws for NYS for COTA’s to complete these documents? I want to do the ethical and right thing to protect my licensure. I was always told to complete on a piece of paper the levels of my patients sort of a cheat sheet and now they are asking us to complete the documents ourselves.

        1. You would need to not only check your NY OT Practice Act, but also the rules and regulations for each insurance carrier to determine what a COTA can and can’t do.

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

      1. An article by Ambury states a PT must “complete the progress note process” and that an assistant cannot complete the task but may be part of the process. That leads me to believe a PTA could open a progress note, take some objective measures and do the daily treatment section….and leave the POC and assessment to be filled in by a PT.
        Is that correct?

  3. 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. 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.

  4. Can an Assistant do a progress note on a Medicaid patient? So they follow same rule as Part B for notes?!

    1. You would need to check with your state practice act to see if an assistant is allowed to write a complete Progress Report. If yes, you would then have to check with your state Medicaid program to see if an assistant is allowed to write a complete Progress Report. If yes, then the answer is yes. If either says no, the answer is no. Keep in mind, as assistant can’t modify a plan of care.

  5. In outpatient, do the same principles apply to the discharge summary? What if a PT writes a progress note and says that the patient will be discharged in 2 more visits – can the PTA then follow that and discharge the patient at that second visit? Would the PT then still need to complete the discharge summary on the date of that last visit? Thanks

  6. Can you please inform me if a PTA, who is practicing in NYS at a skilled nursing facility can write progress notes and do a d/c summary. Thank you

    1. You would need to contact your state therapy association and/or read your practice act regarding what a PTA can and can’t do.

  7. Hey Rick –

    Curious if you received follow up on Item 7 above?

    Additionally, is it okay for a PTA to do their allowed parts of a progress note and then request cosignature from a PT who completes their components of it and the PT signs it?

    Note would show initiated by PTA and co-signed by PT. Is that sufficient?