Health Behavior Assessment Note (HBAI)

(This note documents a Health Behavior Assessment and Intervention focused on behavioral factors impacting a primary physical health condition. Do not include psychotherapy process details.)

(If required information is unavailable, document as "Unknown/not available" with reason and a plan to obtain/clarify.)

Date of Service: [Date]

Setting/Service: [Care setting and service line]

Encounter Type: [in-person / telehealth (video) / telehealth (phone)]

Clinician: [Name, credentials, role]

Participants Present: [Patient alone / Patient + caregiver(s)/family (specify relationship)]; [Interpreter: yes (language/modality) / no]

Referral and Clinical Question

• Referral Source and Contact Route: [Referring clinician/department; contact method]
• Primary Physical Health Condition(s): [Condition(s) being addressed]
• Referral Questions (1–3):
  • [Referral question 1]
  • [Referral question 2] (Only include if provided)
  • [Referral question 3] (Only include if provided)
• Medical Necessity: [Brief statement linking behavioral factors to treatment adherence, symptom control, or health outcomes]

Presenting Problem

[Concise narrative linking the physical condition to behavioral targets] (Include: onset and course of the physical condition with recent trajectory; current medical management; patient understanding and expectations; primary behavior targets with temporal patterns; and prior behavioral interventions tried. Focus on information directly relevant to the behavioral assessment.)

Data Sources and Methods

• [Patient interview] (Brief scope)
• [Collateral information] (Identify source and relationship; include only if obtained)
• [Chart review scope] (Timeframe and key documents reviewed)
• [Questionnaires/standardized measures administered] (Name, purpose, and scores)
• [Device/app data reviewed] (e.g., CPAP downloads, glucometer, wearable activity data; include only if reviewed)
• [Limitations affecting reliability] (e.g., time constraints, language, cognitive barriers; include only if present)

Biopsychosocial Assessment

(Include only domains relevant to this presentation; omit non-applicable domains entirely.)

• Psychological/Emotional:
  • [Stressors and coping related to the medical condition]
  • [Health-related anxiety, catastrophizing, fear-avoidance]
  • [Mood symptoms impacting motivation/energy relevant to regimen]
• Cognitive/Learning:
  • [Health literacy and understanding of diagnosis/regimen]
  • [Memory/attention barriers affecting adherence]
  • [Illness beliefs, stage of change/readiness]
• Behavioral:
  • [Sleep timing/regularity, naps, stimulants/sedatives, variability]
  • [Activity patterns and pacing; graded activity or avoidance]
  • [Adherence behaviors: medication timing, device use, home exercise]
  • [Relaxation or self-regulation strategies used]
• Social/Environmental:
  • [Housing stability, transportation, finances, medication access]
  • [Work demands/caregiver burden impacting regimen]
  • [Social supports and care partner involvement]
• Substance Use: (Include only if assessed; omit entirely if not assessed rather than documenting negatives)
  • [Alcohol/cannabis/other substances as they affect the condition or regimen]
• Strengths and Protective Factors:
  • [Patient motivation/values relevant to health goals]
  • [Supportive relationships/care team engagement]
  • [Prior successful behavior change strategies]

Functional Impact

• [ADLs/IADLs impacted by the condition and behavioral factors]
• [Work/school functioning and attendance/productivity]
• [Condition-specific function (e.g., pain interference, fatigue, daytime sleepiness)]
• [Patient-stated functional goals]

Observations

(Include this section only if clinician observations materially inform the formulation.)

• [Appearance, engagement, distress tolerance, affect relevant to adherence capacity]
• [Insight/judgment as pertains to health behaviors]
• [Objective medical/device data summary (e.g., AHI trends, A1c trajectory)]

Risk and Safety

(Include only if indicated by expressed suicidal ideation, self-harm, severe hopelessness, or high-risk substance use. If assessed and negative, state briefly. Omit entirely if not clinically indicated.)

• [Screening tool and result]
• [Risk level; presence/absence of plan and intent]
• [Protective factors]
• [Mitigation plan: safety planning, crisis resources, warm handoff, higher level of care]

Assessment and Formulation

[2–5 sentence synthesis linking key biopsychosocial drivers to the physical condition and treatment plan] (Clarify whether findings indicate primarily: adherence/logistical barriers, conditioned behavioral patterns, maladaptive coping impacting function, cognitive barriers, social instability, or possible separate mental health condition requiring evaluation. State differential considerations and plan to clarify if applicable.)

Recommendations and Plan

(Organize by problem/target in descending clinical priority. Use separate subsections for each target.)

[Target 1: Behavior or barrier]

• Goal: [Specific and measurable when feasible]
• Rationale: [Link behavioral factor to medical outcome]
• Interventions:
  • Patient actions: [Specifics: frequency, duration, stepwise plan, tracking method]
  • Care team actions: [Referrals, orders, education, coaching, coordination requests]
• Barriers and Mitigations: [Anticipated obstacles and strategies to address]
• Measurement: [What will be tracked and when reassessed]
• Patient Agreement: [Shared decision-making outcome; what the patient committed to try]

[Target 2: Behavior or barrier]

• Goal: [Specific goal]
• Rationale: [Link to medical outcome]
• Interventions:
  • Patient actions: [Specific actions]
  • Care team actions: [Referrals, coordination]
• Barriers and Mitigations: [Obstacles and strategies]
• Measurement: [Tracking plan]
• Patient Agreement: [Patient commitment]

(Add additional targets as needed.)

Care Coordination

• [Team members contacted (referrer, PCP, specialists, PT/OT) and method]
• [Key information shared and specific requests made]
• [Task assignments (patient vs. team) with timelines]

Follow-up

• Timing and Modality: [Timeframe; in-person / telehealth]
• Next Visit Focus: [What will be reassessed (e.g., adherence data, device downloads, symptom/function measures)]
• Contingency Plan: [Instructions if symptoms worsen or safety concerns emerge]

Electronic Signature: [Clinician name, credentials] | [Date/Time]