CBT for Insomnia (CBT-I) Session Note

Date of Service: [Date]

Session Time: [Start time – Stop time / Total duration in minutes]

Modality: [in-person / telehealth] (If telehealth, include patient location.)

Participants: [Participant(s) present] (Include only if someone other than the patient is present.)

Subjective

[Session focus] (State concisely what the session addressed; place this first.)

(Use flowing narrative or brief bullets for interval history.)

• [Interval sleep and daytime functioning since last session]
• [Sleep symptoms: onset, maintenance, early awakenings, quality, timing]
• [Daytime impact: sleepiness, fatigue, concentration, mood]
• [Safety-relevant factors: drowsy driving, safety-sensitive work/activities, precautions taken]
• [Medication and substance changes affecting sleep]
• [Adherence self-report: what was tried, what helped, barriers encountered]
• [Contextual factors: travel, stressors, schedule disruptions]

Objective

Sleep diary: [Source and completeness, e.g., "7/7 nights, app-based"] (If missing or incomplete, document reason and note values are patient-reported estimates.)

• Time in Bed (TIB): [__ hr __ min]
• Total Sleep Time (TST): [__ hr __ min]
• Sleep Efficiency (SE): [__ %]
• Sleep Onset Latency (SOL): [__ min]
• Wake After Sleep Onset (WASO): [__ min]
• Awakenings: [__ per night]
• Sleep quality rating: [__] (If collected.)
• Modifiers: [Naps, caffeine/alcohol timing, other relevant factors]

Assessment

(Interpret response to current sleep prescription using data above.)

• Response to treatment: [improving / plateau / worsening] [Brief rationale referencing SE, SOL, WASO trends]
• Progress toward targets: [SE trend toward goal; SOL/WASO reductions; TST and variability changes]
• Mechanisms and barriers: [Conditioned arousal, schedule irregularity, safety behaviors, maladaptive beliefs, medical contributors]
• Standardized measures: [Measure, score, date] (If administered.)
• Appropriateness for sleep restriction: [Sleepiness burden, safety-sensitive duties, comorbidity considerations]

Plan

• Interventions delivered: [Components addressed and patient response, e.g., sleep restriction titration, stimulus control troubleshooting, cognitive restructuring, relaxation training]
• Sleep window prescription: Bedtime: [__:__] | Wake time: [__:__] | TIB: [__ hr __ min] | [Maintained / Adjusted] (Include SE-based rationale if adjusted.)
• Safety counseling: [Sleepiness management and drowsy driving precautions provided] (Note if restriction modified or paused for safety.)
• Homework: [Diary completion, stimulus control steps, cognitive exercises, relaxation practice]
• Follow-up: [Interval and format; data to bring]
• Referrals/coordination: [As indicated] (Omit if none.)

(If sleep window not adjusted due to missing data or safety concerns, state explicitly and specify what is needed before next visit.)