Progress Report (Therapy Services)

Therapy Services Progress Report

Patient: [name, MRN, DOB]

Discipline/Setting: [PT / OT / SLP]; [outpatient / SNF / home health / inpatient / school / telehealth]

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

Date Written: [date]

Visits This Period: [number completed] (Note missed/canceled visits only if clinically relevant)

Clinician: [name, credentials]

Diagnoses & Precautions

• [Treating diagnosis with ICD-10 code]
• [Additional diagnoses as relevant]
• [Key precautions or medical factors affecting safety, dosing, or goal feasibility] (Limit to factors that materially impact therapy)

Subjective

[Patient/caregiver-reported functional changes since last report, including symptom trajectory, HEP adherence, and intervening events as relevant] (Omit section entirely if no meaningful subjective information obtained)

Objective Measures

(Include only measures actually reassessed this period. If planned measure not captured, note brief rationale.)

• [Measure name]: Baseline [value] ([date]); Current [value] ([date])
• [Functional performance item]: Baseline [level/distance/time] ([date]); Current [level/distance/time] ([date])
• [Additional measures as relevant]: Baseline [value] ([date]); Current [value] ([date])

Goal Progress

(List each active goal with status and evidence. Clearly label goals that are added, modified, or discontinued with rationale.)

• [Goal ID]: [Goal statement or "see POC"]

  Baseline: [baseline performance] | Current: [current performance]

  Status: [Met / Progressing / Not Met / Modified / Discontinued]

  Evidence: [concise justification referencing objective findings]

• [Goal ID]: [Goal statement or "see POC"]

  Baseline: [baseline performance] | Current: [current performance]

  Status: [Met / Progressing / Not Met / Modified / Discontinued]

  Evidence: [concise justification]

• Goal [Added / Modified / Discontinued]: [Goal statement or identifier]

  Rationale: [clinical reasoning for change] (For met goals, include achieved level and date)

Assessment

• Progress Summary: [Improved / Plateaued / Regressed] over this period, supported by [specific objective findings].

• Skilled Need: [Justification for therapist-level services: clinical reasoning, plan progression, safety management, manual techniques, complex cueing, dysphagia safety, equipment modification, caregiver training needs]

• Prognosis: [Good / Fair / Guarded] based on [supporting factors]. (If plateau or regression, explain causal factors and rationale for continued skilled care.)

Plan

• Service Decision: [Continue / Modify / Discharge] at [frequency] for [duration]
• Intervention Focus: [Key treatment priorities for next interval]
• HEP/Caregiver Training: [Updates and training provided as applicable]
• Equipment/Referrals: [Recommendations and status] (Omit if none)
• Next Progress Report: [Date or visit count milestone]
• (If POC changes made: Updated POC will be routed for certification/recertification as required)

Signature: ________________________________ [Clinician name, credentials] Date: [date]

(If assistant contributed to care, include assistant name/credentials and supervising therapist co-signature per state/payer rules)