Mastering Your Assessment Statement in A Progress Report

Progress Note Reporting

When updating your client’s progress in his/her progress note, it is important to justify the need for providing continued skilled care.  This requires you to write a STRONG assessment statement.

Here, you should update:

• The gains your client has made since the initial evaluation or last progress report
• The hindrances to their rate of recovery and ways you are addressing the hindrances.  
  • Make sure these hindrances are varied from progress note to progress note.
  • Also, you need to vary the plan to address hindrances to support continued medical necessity.

Assessment Statement

In your assessment statement, there should be a functional focus on continued care as well as documenting what will be addressed to achieve the goal.  If your client needs continued care due to poor carry over with safety techniques, you may document, “continued skilled OT required for adaptive equipment training and progression of balance activities in order to improve ADLs and decrease falls risk”

Always connect function to your goals in a way that shows how you will address the client’s deficits in order to achieve these outcomes. 

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