Physical Therapy Progress Report (Medicare 10-Visit/30-Day)

Date: [date report written]

Reporting Period: [start date] to [end date]

Episode Start Date: [first visit date]

Visits This Period: [count] | Total Episode Visits: [count]

Patient: [name, DOB]

Diagnosis/Reason for Therapy: [primary therapy diagnosis]

Referring Provider: [name, credentials]

Therapist: [PT name, credentials]

Interval Summary

[Patient-reported functional changes, pain/symptom status, and relevant objective measures since last progress report] (Include key measures tied to goals such as ROM, strength, balance scores, gait parameters, standardized outcome scores. Note current precautions/weight-bearing status and assistive device use. If a measure was not assessed this interval, state "Not assessed this interval" with reason and when it will be obtained.)

• Key Measures: [relevant objective values with units, dates, and tools used]
• Precautions / Weight-Bearing: [current status]
• Assistive Device: [device and use context / N/A]

Goal Progress

(Document each active goal using the format below. Mark met goals. For revised or discontinued goals, include rationale. Assign new identifiers for any new goals.)

• [Goal ID]: [brief goal statement]

  Baseline: [value] → Current: [value]

  Status: [Met / Progressing / Plateau / Regressed]

  Evidence: [objective evidence supporting status]

  If Plateau/Regressed: [contributing factors and planned adjustment] (Omit if Progressing or Met.)

(Repeat for each active goal.)

Assessment

[Clinical interpretation of progress trajectory and response to treatment] (Synthesize objective change and functional impact relative to goals; reference safety risks, comorbidities, and factors affecting progress as applicable.)

Medical Necessity: [rehabilitative / maintenance]

(If rehabilitative) Patient is [improving / demonstrating potential to improve], maximum improvement not yet attained, and continued skilled PT is necessary and expected to achieve remaining goals within a reasonable timeframe. [Specify skilled interventions and clinical decision-making required.]

(If maintenance) Skilled PT is necessary to maintain function or prevent decline; services cannot be safely performed by patient, caregiver, or unskilled personnel due to [clinical complexity or safety risks requiring therapist-level judgment].

(If minimal/absent progress) [Explain barriers and why skilled PT remains justified, or indicate discharge is recommended with rationale.]

Plan

• Frequency / Duration: [e.g., 2x/week for 4 weeks]
• Intervention Focus: [targeted impairments/functional activities linked to goals]
• HEP Updates: [exercises provided, parameters, adherence status]
• Coordination: [provider communications, equipment needs, referrals / N/A]
• Discharge Criteria / Timeframe: [objective criteria and estimated timeframe]
• Next Progress Report Due: [date] (By 10th treatment visit or 30 calendar days, whichever is sooner.)
• POC Update: [N/A / Updated POC sent to physician for recertification on: date]

(If PTA provided care during this interval, document that PT had active participation with at least one billable service during the reporting period.)

Therapist Signature: [PT name, credentials, date]