Discharge Summary (Myofunctional Therapy)

Header

Patient Name: [Full name]

DOB: [Date of birth]

MRN: [Medical record number or local identifier]

Clinician: [Name, credentials, discipline, clinic/organization, contact information]

Referring Provider(s): [Name(s), specialty, contact info] (Omit if self-referred)

Episode Start Date: [Date therapy began]

Discharge Date: [Date of discharge]

Total Visits: [Number completed of number planned; frequency achieved]

Service Mode: [in-person / telehealth / combination]

Discharge Overview

[Reason for therapy and presenting problem in 1–2 sentences] (If referral documentation unclear, state: "Reason for therapy based on patient report; referral documentation not received.")

[Summary paragraph covering key impairments targeted, major interventions used, notable clinical milestones, and overall outcome at discharge including goal attainment status, functional status, and readiness for independent maintenance]

Diagnoses/Problems Addressed

• Primary: [Orofacial myofunctional disorder(s) treated and primary functional impacts] (Use condition descriptions if diagnosis entry is restricted; note referring diagnosis source)
• Contributing Factors: [Relevant items such as nasal obstruction/allergic rhinitis, malocclusion/orthodontic status, ankyloglossia and surgical status, sleep-disordered breathing/OSA, TMD/bruxism, oral habits, feeding/swallow concerns] (Include only applicable factors)
• Known but Not Treated: [Conditions documented but not addressed this episode] (Omit if none)

Interventions Provided

(Focus on intervention categories and skills trained to independence rather than listing every exercise. If documentation of early sessions is incomplete, state that summary reflects available records.)

• Airway/Nasal Breathing: [Education provided; habit retraining approaches; monitoring strategies]
• Rest Posture Retraining: [Lip seal competence training; tongue resting posture/lingual-palatal seal training; jaw posture awareness]
• Swallow Pattern Retraining: [Saliva swallow / liquids / solids training; compensatory strategies; cueing hierarchy] (Specify separately if trained differently; omit if not treated)
• Oral Habits: [Chewing pattern work; habit elimination plan; substitution behaviors] (Omit if not treated)
• Adjunctive Tools: [Biofeedback devices/apps; mirrors; tactile cues; myofunctional devices with purpose] (Omit if none used)
• Interprofessional Coordination: [Requests to other providers; feedback received; therapy adjustments made]
• Episode Procedures/Events: [Frenectomy, orthodontic expansion, or other procedure and therapy modifications around event] (Omit if none)

Status at Discharge

(Provide baseline-to-discharge comparisons where feasible. Use quantified observations—duration, frequency, percent of trials, cueing level—over qualitative terms alone.)

Breathing/Airway

• Predominant breathing route at rest: [Baseline] → [Discharge status with cueing level]
• Lip posture during quiet wakefulness: [Baseline] → [Discharge] (Note conditions that worsen posture)
• Patient-reported sleep symptoms: [Snoring, dry mouth on waking, awakenings, daytime sleepiness] (Label as patient report; omit if not tracked)
• Known airway constraints: [Findings] and [Status of ENT/allergy/sleep referrals]

Rest Posture

• Lips: [Baseline] → [Discharge: competence at rest with duration maintained and cueing level]
• Tongue: [Baseline] → [Discharge: resting location and ability to achieve/maintain lingual-palatal seal with duration and cueing]
• Jaw: [Baseline] → [Discharge: posture and freeway space] (Omit if not assessed or not relevant)
• Carryover: [Performance in structured tasks vs. spontaneous conversation with cueing level]

Swallow Function

(Include when swallow was a treatment target. State if conclusions are based on clinical observation only and whether instrumental assessment occurred elsewhere. If swallow not treated, replace this subsection with: "Swallow pattern not a treatment target in this episode.")

• Saliva swallow: [Baseline] → [Discharge: % accurate, consistency, cueing]
• Liquids swallow: [Baseline] → [Discharge: volume/consistency tested, % accurate, cueing]
• Solids swallow: [Baseline] → [Discharge: bolus control/chew-swallow sequence, % accurate, cueing]
• Safety observations: [Coughing, choking, wet voice, or other signs] (Clinical observation only unless instrumental results available; omit if not assessed)

Additional Domains

(Include only applicable domains below; omit entire subsection if neither applies)

• Speech/Articulation: [Sounds targeted; current accuracy and carryover status] (If not treated: "Speech not a treatment target.")
• Orthodontic Context: [Phase of treatment] and [Observed interactions between oral posture and orthodontic stability] (Label as clinical impression)

Patient-Reported Function

[Brief statement of functional changes from patient/caregiver perspective such as reduced daytime mouth breathing, improved lip seal maintenance, meal efficiency] (Include direct quote only if particularly salient)

Goal Attainment Summary

(Order by priority: airway/breathing stability, rest posture, swallow, then adjunct goals. Do not mark goals as met without documented observable criteria.)

• Goal: [LTG/STG] [Domain] [Target behavior] [Measurement method]

  Status: [Met / Partially Met / Not Met / Discontinued]

  Discharge Performance: [Objective result with cueing level]

  Notes: [Barriers, facilitators, generalization status, maintenance expectations]

• (Repeat for each goal)

Discharge Disposition

Disposition: [completed plan of care / transitioned to maintenance program / transferred to another provider / patient-requested discharge / nonattendance / medical hold / insurance/payer limitation / goals met / plateau/maximum benefit / moved/relocated]

Details: [If goals met: specify domains and measures demonstrating readiness. If plateau/max benefit: provide objective evidence and remaining barriers. If nonattendance/patient choice: document contact attempts, education provided, and safety guidance.]

Risk Level at Discharge: [low / moderate / high] — [Brief rationale such as unresolved nasal obstruction, ongoing habits, orthodontic instability phase, limited adherence history]

Residual Deficits & Relapse Risks

• [Residual deficit]: Triggers: [likely triggers] | Mitigation: [strategy] | Escalation: [criteria for re-evaluation or medical review]
• (Repeat for each residual deficit; label clinical impressions as such)

Home Maintenance Plan

(If patient is not appropriate for independent maintenance, document need for continued skilled follow-up instead of home program.)

• Daily Routine: [Specific activities with frequency, duration, and context: breathing practice; rest posture checks with context-based reminders; tongue-palate seal practice with duration targets; swallow practice by task type]
• Self-Monitoring Tools: [Timers, phone reminders, mirror checks, caregiver prompts, habit trackers]
• Progression/Regression: [How to reduce frequency when stable; how to increase practice if relapse signs appear]
• Boundaries: [Activities not advised without clinician oversight]
• Materials Provided: [Handouts, links, device instructions, video home program] (Reference attachments rather than pasting content)

Follow-Up & Recommendations

• Recommended Follow-Up: [Myofunctional check-in timing if offered] and [Follow-up with ENT/allergy/orthodontics/dentistry/sleep medicine with timeframes]
• Pending Items: [Pending evaluations, tests, referrals, or provider decisions with responsible party noted] (If none: "No pending studies or referrals from this episode.")
• Return-to-Care Criteria: [Specific triggers such as recurrent lips-apart posture most of the day, return of tongue thrust swallow, persistent dry mouth on waking, renewed snoring, orthodontic relapse concerns]
• Recommendations to Other Providers: [Recipients of this summary; specific clinical recommendations for evaluation/monitoring; requests such as addressing nasal obstruction] (Clearly separate therapy-achieved functional skills from medical/dental etiology resolution; omit if self-referred with no other providers involved)

Patient/Caregiver Education

Topics Covered: [Breathing goals, posture, swallow strategies, relapse signs, follow-up plan]

Method: [verbal / written / demonstration / teach-back]

Understanding: [Comprehension based on teach-back or return demonstration] (If teach-back not performed, document method used and any observed gaps without implying comprehension)

Signature

Clinician Signature: [Electronic signature]

Credentials: [Full credentials]

Date/Time Signed: [Date and time of authentication]