Habit Elimination Program Note (Thumb, Pacifier, or Oral Habits)

Date: [Date]

Patient Name: [Patient full name]

DOB: [MM/DD/YYYY]

Provider: [Provider name, credentials]

Visit Type: [initial evaluation / follow-up]; [in-person / telehealth]

Reason for Visit

[Stated concern from caregiver and/or child; target habit(s) being addressed; purpose of today's visit] (Present as a short paragraph or 2–3 brief lines. A brief quote is acceptable if motivation is clinically relevant.)

Subjective

Information source: [caregiver / child / both] (Attribute reports to source throughout.)

Habit history (initial visit): [Type and laterality; onset and course; frequency, duration, and intensity; timing and triggers; function the habit serves; prior cessation attempts and outcomes; associated impacts such as skin changes, dental concerns, or psychosocial effects] (Summarize as a brief narrative paragraph.)

Interval progress (follow-up): [Tracking results; adherence to plan components; barriers encountered; adverse effects from interventions if any] (Use comparative language to show trajectory since last visit.)

Readiness assessment:

• Child: Importance [0–10]; Confidence [0–10]; [brief supporting statement if offered]
• Caregiver: Importance [0–10]; Confidence [0–10]; [brief supporting statement if offered]
• Assent: [Child assents to plan / declines / not developmentally appropriate]

(If readiness not assessed, document reason.)

Objective

[Pertinent oral and dental findings related to the habit; digit findings if applicable; relevant diagnostics obtained] (Include only clinician-observed or measured findings. If examination limited or not performed, state explicitly with reason.)

Assessment

(Problem-oriented; limit to 2–4 items. Include status on follow-up visits.)

1. [Primary habit]: [clinical significance and current status]
2. [Associated dentofacial or behavioral finding if applicable]: [significance and status]
3. [Key barrier to success if applicable]: [brief description]

Plan

(Collaborative, non-punitive behavioral approach. Document as integrated content.)

• Goal: [Target habit]; [measurable goal] within [timeframe]
• Reinforcement approach: [Positive reinforcement strategy; criteria for rewards; planned response to slips]
• Strategies: [Environmental/trigger management; replacement or self-soothing alternatives agreed upon]
• Caregiver education: [Topics covered]; understanding [confirmed / needs reinforcement]
• Tracking: [Method and accountability tool]
• Appliances/referrals: [Indication, consent discussion, and monitoring plan] (Include only if discussed.)
• Follow-up: [Timing]; [specific agenda items for next visit]

(If any plan element not addressed, document reason. Use objective, non-judgmental language throughout.)