What to do when a patient is progressing well with their current therapy?

Documenting Patient Progress in Therapy

When a patient is progressing well with their current therapy, the treatment plan should be continued with documentation that clearly specifies objective evidence of improvement or stabilization. 1

Key Components for Documenting Patient Progress

Assessment of Response to Treatment

• Document at least two of the following factors over consecutive visits (typically 3-6 months apart) to establish improvement or stabilization 1:
  • Decrease in symptoms (e.g., reduced breathlessness, decreased cough frequency/severity)
  • Reduction in physical findings (e.g., improved imaging findings)
  • Measurable physiologic improvements (e.g., improved pulmonary function tests, lab values)

Specific Documentation Elements

• Symptom changes: Document specific improvements in patient-reported symptoms with quantifiable measures when possible 1
• Objective measurements: Include relevant test results showing stability or improvement (e.g., "PFTs show 12% improvement in FEV1 from baseline") 1
• Functional status: Note changes in activity tolerance, quality of life, or performance status 1
• Treatment adherence: Document patient compliance with the prescribed regimen 1
• Adverse effects: Note presence or absence of treatment-related side effects 1

Recommended Documentation Format

• Begin with a clear statement of overall progress (e.g., "Patient demonstrates favorable response to current therapy as evidenced by...") 1
• Provide specific, measurable evidence supporting continued improvement or stabilization 1
• Include time frame of improvement (e.g., "over the past 3 months") 1
• Conclude with clear continuation plan (e.g., "Will continue current treatment regimen at same dosage") 1

Treatment Continuation Guidelines

For Patients Showing Improvement

• Document specific improvements using objective criteria 1
• Continue therapy at current dosage 1
• Schedule appropriate follow-up intervals based on condition and treatment type 1

For Patients Showing Stabilization

• Document evidence of disease stabilization 1
• Continue therapy at current dosage 1
• Consider longer-term maintenance strategy if appropriate 1

Duration of Continued Therapy

• For many conditions, therapy should continue for at least 6 months before major reassessment 1
• After 12-18 months, individualize therapy based on documented response and tolerance 1
• Consider indefinite continuation only with objective evidence of continued benefit 1

Common Pitfalls to Avoid

• Failing to document objective measures of improvement 1, 2
• Using vague terminology without specific evidence (e.g., "doing better") 3, 4
• Omitting quantifiable changes in symptoms or function 2, 5
• Not addressing treatment adherence or side effects 1, 5
• Continuing therapy without documented benefit beyond 18 months 1

Clinical Example

"Patient is progressing well with current therapy as evidenced by: 1) Increased exercise tolerance (now able to climb one flight of stairs without stopping, compared to baseline of 3 steps); 2) Reduction in supplemental oxygen requirements from 3L to 1L at rest; 3) Improvement in PFT values with FEV1 increased by 15% from baseline. Patient reports good medication adherence with minimal side effects. Plan: Continue current treatment regimen at same dosage with follow-up in 3 months to reassess response." 1, 2