What is a Rolling-History Progress Note?

A rolling history progress note will carry forward the prior note and add an addendum section to each of the following sections:

  1. HPI
  2. Injured body part physical exam
  3. Work Restrictions

Each of these three progress note sections will become a running history documenting the initial visit information and all subsequent follow-up visits.

Example of a Running-History Note on the Third Follow-up Visit

History of Present Illness

On 1/3/2021, this 44 year old machinist slipped on an oily floor, falling forward breaking his fall with both outstretched hands and striking the floor with the right knee.  He had immediate severe right knee pain but was able to stand unassisted.  He walked with a limp due to right knee pain and was sent home to rest.

He took ibuprofen, elevated his knee, and applied ice packs.  The pain was not improved the following day and he still has a limp when walking.  He had no discomfort in the other knee or either of his hands.   He was then sent to an Occupational Medicine clinic for further evaluation.

He has no prior injury to either knee or hands and denies any history of chronic pain in the right knee.

 

DATEAdditional HPI Information on Subsequent Visits
01/4/2021Initial visit, 1 day after injury.  Pain has improved only slightly, and patient persists with limp, favoring right knee.  He reports 5/10 pain with activity, and inability to squat or kneel.  Climbing stairs is painful.
1/11/2021One week post-injury.  Knee pain with ambulation has improved 50% to 3/10, with an increase in ability to flex the right knee.  Still unable to squat or kneel due to increased right knee pain.  Has completed physical therapy x 2 sessions, which the patient feels is helping.  Taking ibuprofen with partial relief of pain.
1/18/2021Two weeks post-injury.  Right knee pain is 2/10.  Patient able to climb stairs without difficulty but avoids squatting or kneeling.  Reports no difficult with carrying up to 40 lbs.  Continuing with physical therapy weekly.
 

Physical Examination

In the physical exam section, any involved body parts are documented in a table format, with additional rows being added as needed for each subsequent visit date.

RIGHT KNEE
1/4/2021Initial evaluation.  Medial 3+ tenderness and mild swelling medial knee.  ROM flex 0-90 limited by medial pain.  No skin abrasions.  No patella grate or apprehension.  Medial joint line tenderness.  No anterior or lateral joint line tenderness.  Valgus stress produces medial pain with no laxity.  Varus stress produces no pain with no laxity.  McMurray negative for pain or click.  Weighted pivot negative.   Unable to squat more than 50% or kneel due to pain.
1/11/2021One week post-injury.  Knee pain with ambulation has improved from 6/10 to 3/10, with an increase in ability to knee flex.  Still unable to squat or kneel due to increased right knee pain.  Started physical therapy, which the patient says helps.  Taking ibuprofen with partial relief of pain.
1/18/2021Two weeks post-injury.  Right knee pain is 2/10.  Patient is able to climb stairs but avoids squatting or kneeling.  Reports no difficulty with carrying up to 40 lbs.  Continuing with physical therapy weekly.

Work Restrictions

Work restriction forms are usually generated as forms independent of the progress note, so they can be delivered to the employer.   However, they represent important objective evidence of progress or lack of progress.  This information is considered by the provider to determine if the patient’s progress is on track.  It is also important for the case manager, and sometimes Utilization Review to see this information to make decisions on authorization requests.  Having it conveniently documented in history form is a great benefit to physicians, case managers, and utilization reviewers, and saves them from having to view each Work Status report individually.

Creating this Work Restriction history does not add much time spent on the progress note, since the contents can be “cut and pasted” into the separate Work Restriction form.  Also, with each follow-up visit, the prior work restrictions are cut and pasted into the current restrictions, and only changes from the prior status needs to be edited.

 

WORK RESTRICTION HISTORY
1/4/2021No lift, push, pull, carry more than 20 lbs.  No squatting, kneeling or crawling.  Limit stair climbing to one flight.  Limit walking to 100 feet.  Allow sit down breaks of 10 minutes every hour, if necessary, due to knee pain.
1/11/2021No lift, push, pull, carry more than 40 lbs.  No squatting or kneeling or crawling.  Limit stair climbing to 2 flights.  Limit walking to 500 feet.  Allow sit down breaks of 5 minutes every 2 hours, if necessary due to knee pain.
1/18/2021No lift, push, pull or carry more than 50 lbs.  May kneel with knee pad.  No squatting.

Five Advantages of the Rolling-History Progress Note

1.  Providers can Review of Patient History and Progress Notes Faster

Patient history can be reviewed fast prior to each subsequent visit, with all pertinent information contained in one document.  This avoids having to click through multiple progress notes, imaging reports, and work status reports to get up to speed exactly where the patient is in his recovery process.

This benefits the treating provider, allowing them to recall quickly exactly the status of the patient, especially when several patients with a similar diagnosis are currently being treated.  The review is important to avoid confusing the patient with other patients with similar conditions.

2.  Colleagues can Review Patient History and Progress Faster

Colleagues of the treating provider may see the patient when the provider is not available.  They also need to quickly the history and progress for continuity of care.  Being able to do this efficiently is even more important for colleagues since they do not know the patient well from prior visits.

3.  Specialist Referrals Appreciate Have All the Information in a Single Document

The rolling progress note format benefits referrals to specialists, as it allows them to quickly screen the referral for appropriateness and also render treatment decisions with less time spent collecting all of the needed data from multiple sources.

4.  Benefits for Case Managers and UR Reviewers

Authorization requests are reviewed by the insurance company case managers.  They have the ability to approve requests that are clearly within the normal guidelines.  However, anything not obviously within the guidelines is sent to Utilization Review.

It is the responsibility of the case manager to forward all the necessary records to Utilization Review so they can make a decision on the authorization request.   Herein, lies the problem.  Case managers are busy, and do not always have time to search for all the records that Utilization Review may need.  They also do not always know which records will prove to be important for the Utilization Review determination, especially for surgical procedures authorization requests.

The records from the case manager are usually delivered to Utilization Review just before the administrative deadline for responding to the request.  The treating provider has no control over what the case manager will deliver to Utilization Review.  When Utilization Review receives the authorization request so close to the administrative deadline, it does not have much time to make additional requests for any records that are missing and needed for a decision.  They may make a phone call to the physician’s office in an attempt to get the necessary records, but they often play phone tag with medical offices before they can obtain the needed records.  Since they must respond to the request before the administrative deadline, they often deny the request because the submitted documentation is not sufficiently complete to support the request.

5.  Rolling-History Progress Notes Help Reduce Denials

While case managers do not always forward all pertinent documents to the Utilization Review team, they almost always include the most recent progress note.  If a running progress note is used, it will contain a complete history of the injury, from the date of injury to the present time, objective evidence of improvement, or lack of improvement, and history of imaging reports.

A Utilization Review decision can often be made on the basis of this current progress note alone, without resorting to also seeking this information from multiple notes from Physical Therapy, or Imaging Reports.  When the treating physician submits this information as a group of separate documents, there is no guarantee that all of the needed documents will be kept together and forwarded to Utilization Review.  Keeping all important information contained in a single note makes it less likely that the authorization request will be denied due to insufficient documentation to support the request.