Health Behavior Assessment Note (HBAI)

Date of Service: [Encounter date]

Clinician: [Clinician name, credentials]

Encounter Type: [Initial HBAI Assessment / HBAI Reassessment]

Total Time: [Total minutes]

Setting/Modality: [outpatient / inpatient / telehealth / other: specify]

Participants Present: [Patient present: yes/no; others present: family/caregiver/interpreter names and roles] (If interpreter used, identify language.)

Referring Clinician: [Name, service/clinic] (Include only if available.)

Service Framing and Medical Necessity

[Brief statement identifying this encounter as a Health & Behavior (HBAI) assessment focused on biopsychosocial factors affecting self-management of: [physical health condition].]

[Medical necessity rationale: targeted self-management problem(s), suspected barrier domains, and why behavioral assessment is needed now to improve adherence, symptom control, or function. If relevant, note what is distinct from the medical E/M assessment.] (Use condition- and task-specific language. If information is missing, state Unknown with plan to obtain.)

Physical Health Condition

Primary physical diagnosis/condition: [Condition name] (Include ICD code only if required by local policy.)

Date of initial diagnosis: [Known date / Unknown] (If unknown, indicate plan to confirm.)

Current treatment regimen relevant to self-management: [Medications with purposes, monitoring tasks, rehab/therapy plan, diet/activity restrictions, devices/equipment and required use schedule] (Summarize what the patient is expected to do; avoid duplicating the full medical record.)

Recent clinical course relevant to barriers: [Exacerbations, hospitalizations, complications, recent procedure/regimen changes] (Include dates if known; state Unknown if not available.)

Functional impact: [Impact on ADLs, school/work, or role function as it relates to behavioral targets] (Include only if relevant.)

Reason for Visit

[Focused summary (3–8 sentences): patient's stated goal or concern with brief direct quote if illustrative; specific self-management behavior(s) for assessment; onset/course and context (new diagnosis vs. longstanding, recent complications); immediate trigger for referral or timing.] (Keep condition-focused rather than broad psychosocial history.)

Data Sources

[Data sources informing this assessment: patient interview; chart review (key items); collateral contacts (name/relationship); standardized instruments administered; interpreter used (language).] (Omit this section entirely if assessment was based solely on patient interview with no tools administered.)

Biopsychosocial Assessment

Self-Management Behaviors

• [Medication-taking patterns: routine, missed doses, timing, refill behaviors, use of reminders; barriers/facilitators]
• [Appointment adherence: attendance, cancellations/no-shows, scheduling barriers]
• [Symptom/disease monitoring: what is monitored, frequency, accuracy, device proficiency, logging/sharing of data]
• [Rehab/home exercise or therapy program adherence: frequency, technique, barriers]
• [Nutrition plan adherence: recommendations followed/not followed, trigger contexts, meal access/prep constraints]
• [Sleep behaviors impacting condition: schedule, duration, disruptions] (Include only if condition-relevant.)
• [Other regimen-specific behaviors: device maintenance, wound care, use of supports] (Include only if applicable.)

(For domains not assessed, state Not assessed with reason.)

Barriers and Facilitators

• Cognitive/capacity: [Orientation, attention, memory, comprehension of regimen, health literacy, teach-back performance] (Link to specific self-management tasks.)
• Emotional/adjustment: [Condition-related distress, fear/avoidance, demoralization, pain-related distress] (Describe impact on tasks; avoid mental health diagnoses unless necessary and within scope.)
• Behavioral skills/habits: [Routines, cueing strategies, planning/organization, competing demands, environmental cues]
• Health beliefs/illness perceptions: [Perceived benefits/risks, misconceptions, fatalism, stigma, explanatory model]
• Motivation/readiness: [Stage of change, confidence/self-efficacy, values congruence, change talk/sustain talk]
• Social/family system: [Caregiver availability, role clarity, family behaviors that support or undermine adherence]
• Cultural/language: [Language concordance, cultural norms affecting regimen, trust in health system, preferred learning style]
• Social determinants/access: [Transportation, housing stability, food security, financial/insurance barriers, pharmacy access]
• Substance use: [Type/patterns; direct impact on medications, devices, or recovery] (Include only if relevant to medical management or safety.)

(For each applicable domain, connect how the factor impedes or facilitates the targeted self-management behavior. Mark Not assessed with reason for any domain not covered.)

Strengths and Protective Factors

• [Prior successful behavior changes and how achieved]
• [Social supports and caregiver engagement]
• [Values/goals aligned with adherence and health improvement]
• [Practical resources: reminders/apps, pill organizers, transportation assistance, patient portals/devices]

Behavioral Observations and Capacity

[Appearance/behavior; engagement/effort; mood/affect in relation to health tasks; cognition sufficient for participation.] Capacity: [Statement regarding patient's ability to understand and respond meaningfully to assessment and recommendations, or describe specific limitations.] (Expand mental status elements only if impairment is suspected or clinically relevant.)

Risk and Safety

[No acute safety concerns elicited or observed today. / Safety concerns identified: what was endorsed/observed, severity/immediacy, and actions taken (safety planning, crisis resources, referral, mandated reporting).]

Standardized Measures

• [Instrument name]: Score [total and key subscales]; Interpretation: [plain-language meaning and relevance to self-management]; Re-administration plan: [interval and purpose]
• [Instrument name]: Score [values]; Interpretation: [meaning]; Comparison to prior: [baseline vs. current] (Include if available.)

(If no measures used, state reason and whether planned for follow-up. If mood/anxiety screeners used, link results to self-management impact and note if mental health referral is warranted.)

Clinical Formulation

[Synthesis linking identified biopsychosocial factors to: medical condition course/symptom management, specific adherence/self-management behaviors, and functional outcomes. State how assessed barriers/facilitators are expected to influence health behaviors and inform the plan.] (Attribute source: patient report, chart, observed. Avoid diagnosing mental disorders unless necessary and within scope; document observed symptoms and impact with referral if indicated.)

Plan of Care

Goals:

• [Goal 1: Specific behavior target, measurement method (self-report log / device data / refill history / PROM), timeframe]
• [Goal 2: Specific behavior target, measurement method, timeframe]

Recommended Interventions: [Modality/approach; skills to be taught; homework/practice plan tied to goals]

Frequency and Duration: [Visit frequency, expected number of sessions or duration, criteria for discharge (goal attainment, plateau, escalation/referral)]

Referrals/Resources: [Referrals to medical team, pharmacy, social work, nutrition, PT/OT, mental health, community resources] (Include only if applicable.)

(If only assessment was completed with no intervention recommended, state rationale and alternative supports.)

Care Coordination

[Information to be communicated to treating medical clinician/team]; [Mode: EHR message / team huddle / consultation note / phone]; [Specific requests or considerations for the medical team] (If no coordination needed, state why.)

Reassessment Addendum

Change Trigger: [Date and precipitating event prompting reassessment: hospitalization, new complication, regimen change, life change affecting adherence]

Progress Since Last HBAI: [Goal-by-goal status: met / partially met / not met with evidence; barriers resolved, persistent, or new]

Updated Outcome Measures: [Repeat scores with interpretation and comparison to baseline]

Plan Updates: [Continue / adjust frequency / modify targets or interventions / initiate discharge planning with criteria and timeline]

(Include this section only for HBAI Reassessment encounters.)

Signature

[Electronic signature, credentials, date/time] (If late entry or addendum, clearly label as such with entry date/time.)

(When information is missing, document Unknown with plan to obtain or Not assessed with reason—do not leave required elements blank. Attribute sources for key clinical claims. Prioritize documentation linking directly to targeted self-management behaviors and medical plan.)