Progress reports and discharge summaries

A progress report summarizes how a patient did over a reporting period: progress on each plan of care goal, whether the goals change, and why skilled treatment should continue. A discharge summary does the same at the end of care and closes the episode.

Write both from the Documentation tab on the patient's chart: click New Document and choose Progress report or Discharge summary as the type. For recertifications, see Plans of care.

Goal progress over the period#

The goals section of a progress report or discharge summary lists the plan of care goals, each on its own card. Short-term goals sit indented under their long-term goal. Each card shows:

• a chart of the results recorded on daily notes since the last progress report, by date. The target is a dashed line, and the baseline a dotted one when the goal's baseline starts with a number ("40% accuracy at evaluation"). Point at a dot to see its date and result; a hollow dot is a note not signed yet. Cueing-level goals chart from maximal cues at the bottom to independent at the top. Enlarge at the top of the card shows the chart over the whole screen, and Export saves that goal's chart as a PDF or PNG image with its target and baseline.

• numbered amber lines for the patient's goal chart events in the period, such as an illness or a new device, with the list under the chart ("1. Sep 10 Illness: ear infection"). The exported image and the PDF carry the same lines and list.

• the First and Last result with their dates, the Average and the number of Readings. A note that counted trials shows its total next to the result ("7/10, 70%"), on the card, in the chart and in the PDF.

• a trend badge read from the results: Met once the latest result reaches the target, otherwise Progressing, Plateau or Regressing by how the results moved over the period, or Too few readings.

• a forecast line, when the goal has a target and at least three days of results: the date the results reach the target if they keep their pace (On track to meet the target by a date), or Behind schedule in red when that date falls after the goal's target date, the target date has passed, or the results are not moving toward the target. NeatPractice draws a straight line through one result per day (several results on one day are averaged) and reads where it meets the target, as of the last day of the report's period. When the period has results on fewer than three days, NeatPractice also reads the 90 days before the period starts, and the forecast line says so and from which date. A goal already at its target, or with too few results even then, shows no forecast.

The trend and the forecast are a guide only, worked out by a fixed rule rather than AI. You write the status of each goal yourself; NeatPractice never sets it for you.

Completeness and chart sections#

While an evaluation, re-evaluation, progress report, plan of care, recertification or discharge summary is a draft, a Completeness card under the sections lists each section in order with what it still needs:

Click an unfinished section's name to jump to it. The card refreshes each time the draft saves.

Sections built from From the chart fields show the patient's demographics, coverage or authorizations read only. Update the chart, and the draft shows the change; once signed, the document keeps what it showed and prints it as a table.

Drafting sections with AI#

When your clinic has progress report and discharge summary drafts on and the discipline offers the AI narrative, long sections of a progress report, re-evaluation, recertification or discharge summary show an AI button. The draft uses the reporting period (since the episode's last signed plan or report), the visits and signed notes in it, each goal's measured trend, outcome scores and the authorizations that cover it. Edit the draft, then click I Reviewed the Draft; signing waits until you do.

Print a progress report#

Choose Print Draft in the More actions menu at the bottom of a draft to save it as a PDF, charts included. NeatPractice saves your typing first; the PDF is marked Draft, not signed and is not kept. Once signed, choose Print or Send > Print for the signed copy.

A progress report or discharge summary also lists the patient's outcome measure results in its period, with a chart per instrument and person who answered. It takes the results recorded in the report itself, results recorded outside a note for an instrument of the report's discipline (or of every discipline), and results in signed notes of its discipline that the report's author may read. Results in a note that is still a draft are left out, since they can still be voided.

When you sign the report, NeatPractice locks the goal progress and the outcome results of its period with it. Notes signed later for the same dates do not change a signed report, and its signed copy draws each goal's card with the same chart, trend, forecast, chart events, results, status and notes. Chart events added, changed or removed later never reach a signed report.

When a progress report is due#

NeatPractice counts treatment days for each episode: the dates with a signed visit that has at least one service. The count starts over after each signed progress report or re-evaluation written by a therapist. Reports written by an assistant, student or aide do not restart the count.

The rule that applies comes from the billing rules of the payer on the visit (see Payers):

Patients without a payer rule use the warn-only rule with the visits and days in their discipline's module settings (10 visits or 30 days to start).

The warning shows at the top of a draft daily note and in the visit window. A progress report that is due also appears in the treating therapist's due items on the schedule and in the Progress reports due widget on their dashboard, and links to the patient's Documentation tab. When an assistant treated the patient, the item goes to the supervising therapist.

Sign past the progress report rule#

Users who can override documentation gates, such as clinic admins, see a Reason to sign before the progress report field when a note is stopped. Enter the reason and click Sign again. The reason is kept with the note for review.

Discharge summaries close the episode#

Signing a discharge summary discharges its episode of care: the episode's status becomes Discharged, with the summary's date as the discharge date and the Discharge reason chosen on the summary. When every episode of the patient is discharged, the chart suggests marking the patient Discharged.

A discharge summary can be written for any episode, with or without a visit, and is never stopped by the plan of care or progress report rules.

Transfer and next level of care#

The stock discharge summary templates include a Transfer and next level of care section, so the record says where care goes next:

• Next level of care (required): no further services, a home program only, fewer visits at your clinic, school-based services, an early intervention program, another outpatient provider, more intensive care, or other (describe it in Other level of care).
• Care transferred to another provider: when Yes, name the Receiving provider or program (required) and add its phone or fax, the Transfer date and whether Records sent to the receiving provider.
• Hand-off notes: what the next provider should know, such as what worked and open concerns.

To send the records, use Print or Send on the signed summary (for example a fax to the receiving provider). Clinics that built their own discharge template can add the section from the template catalog.