Health & Behavior Intervention Progress Note (Pediatric)

Health & Behavior Intervention Progress Note (Pediatrics)

Patient: [name, DOB, age]

Date: [encounter date]

Provider: [name, credentials]

Time: [start time] to [stop time]; [total] minutes face-to-face

Session Format: [individual / family / caregiver-only] with [participants present]

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

(If adolescent: briefly note confidentiality boundaries discussed. If consent/assent required by local policy, confirm obtained. Omit if not applicable.)

Medical Condition & Visit Purpose

Follow-up HBAI intervention for [behavioral target(s)] affecting [physical health condition(s)].

• [Medical diagnosis targeted and current clinical status, including recent exacerbations, treatment changes, or functional impact]
• [Behavioral/psychosocial factors affecting medical management, e.g., adherence barriers, symptom-related avoidance, sleep disruption, caregiver patterns]
• [Reference to prior visit plan being continued or adjusted]

Interval Update

(Organize by behavioral target. For each target, include relevant items below; omit any not applicable.)

• [Behavioral Target]: [patient/caregiver report of frequency, symptom or functional impact, homework completion and barriers since last visit] (Include objective data from logs, devices, or records if available.) (Note relevant contextual changes such as new medical recommendations, family stressors, or schedule changes.)

(Repeat for additional behavioral targets as needed.)

Behavioral Observations: [cooperation, affect, attention, or other observations relevant to engagement or capacity] (Include only if clinically relevant.)

Standardized Measures: [instrument name, score, date, interpretation tied to function or health behavior] (Include only if administered.)

Safety Screening: [screen performed, results, actions taken] (Include only if performed; omit if not indicated.)

Interventions Delivered

(Document what was done, not just discussed. Name specific techniques.)

• [Behavioral Target]: [specific technique or skill] — [what it addressed and how applied in-session]

(Repeat for each distinct intervention or target.)

• Developmental Adaptations: [play-based elements / visual supports / caregiver coaching role] (Include only if relevant.)
• Materials Provided: [trackers, handouts, apps] (Include only if provided.)
• Engagement: [participation quality and barriers observed during session]

Response & Progress

(For each behavioral target, summarize response to today's intervention and measurable progress compared to baseline and last visit.)

• [Behavioral Target]: [response today including understanding, skill performance, readiness, barriers]; [progress metrics with baseline and current comparison, e.g., adherence days/week, missed doses, symptom frequency, sleep latency, school attendance] (If progress is limited, note adjustments made to goals or strategy.)

(Repeat for additional behavioral targets.)

Plan & Care Coordination

Home Practice:

• [Target]: [specific task/skill]; [frequency]; [who is responsible]; [anticipated barriers and coping plan]

(Repeat for each home practice assignment.)

Follow-up: [next visit timing and format]

Referrals: [referral made or recommended, purpose, patient/family agreement] (Include only if applicable.)

Medical Team Communication: [summary of information sent to referring clinician: current targets, progress metrics, barriers, recommendations] — [method] on [date] (If pending, note plan and timeframe.)

Safety/Mandatory Reporting: [actions taken and rationale] (Include only if occurred.)

Diagnosis (HBAI Billing): Primary: [physical health condition]; Secondary: [behavioral/psychosocial factor affecting health]

Provider Signature: [name, credentials, date/time]

Supervising Provider: [name, credentials, attestation statement, date/time] (Include only if supervision attestation required.)