Home Program Adherence & Barrier Log (Myofunctional Therapy)

Patient name and identifiers per facility policy: [Patient identifiers]

Note date and time: [Date and time]

Clinician name and credentials: [Name, credentials]

Encounter modality: [in-person / telehealth / asynchronous]

Home practice measurement period: [Date range covered by adherence data]

Data sources used: [patient report / caregiver report / paper log / app log / device report / video review / other] (Indicate all that apply.)

Program Snapshot

[Program phase or week number; primary therapeutic targets (1–3 such as nasal breathing, tongue resting posture, lip seal, swallow pattern); current home program version or date last updated; relevant precautions affecting home practice]

Prescribed Home Program

(If home program is currently on hold, state "Home program on hold—[reason]" and omit the table.)

Exercise name	Prescribed dose	Critical technique elements (1–3 key cues)	Allowed modifications
[Exercise 1]	[Reps/sets, hold duration, sessions per day, days per week]	[Technique cues]	[Modifications if specified, or "None specified"]
[Exercise 2]	[Dose]	[Technique cues]	[Modifications]
[Additional exercises as applicable]	[Dose]	[Technique cues]	[Modifications]

Adherence Metrics

Total sessions completed vs prescribed: [Completed] / [Prescribed] ([Percentage]%) — Data source: [patient report / caregiver report / app timestamps / device display / paper log / video review]

Exercise name	Planned count	Completed count	% completed	Technique fidelity
[Exercise 1]	[Planned]	[Completed]	[Percentage]%	[Quality rating or % correct, if assessed]
[Exercise 2]	[Planned]	[Completed]	[Percentage]%	[If assessed]
[Additional exercises as applicable]	[Planned]	[Completed]	[Percentage]%	[If assessed]

Data quality: [Counts are patient-reported / caregiver-reported / objectively verified via app timestamps, video review, or device display] (Do not infer adherence from clinical improvement alone.)

Adherence pattern synthesis: [Brief note of patterns such as clustering of missed days, weekday vs weekend differences, or time-of-day consistency]

Data gaps and tracking plan: [If adherence data unavailable or incomplete, state reason and tracking plan established for next period] (Use "Complete data obtained" if no gaps.)

Barriers to Adherence

Barrier status: [Barriers present / No barriers reported / Not assessed—reason]

(When barriers are present, document each below. If a barrier suggests a condition outside therapy scope, document observations and referral recommendation rather than a diagnosis.)

• Barrier: [time/scheduling / forgetfulness / motivation / instruction misunderstanding / discomfort / fatigue / nasal obstruction or illness / travel / psychosocial factors / technology issues / access or equipment / other]
  Description: [Brief description and context; include brief patient quote if clarifying]
  Frequency and impact: [How often barrier occurs; effect on adherence such as missed count or percentage]
  Safety relevance: [Yes—explanation / No]
  Referral recommendation: [If indicated, e.g., medical evaluation for nasal obstruction]
• [Additional barriers as applicable]

Facilitators and Strengths

Facilitator assessment: [Assessed / Not assessed—reason]

• Facilitator: [Helpful routine, reminder system, caregiver participation, self-monitoring ability, symptom improvement reinforcing behavior, environmental support] — Effect: [How this supports adherence or technique quality]
• [Additional facilitators as applicable]

Coaching and Skilled Interventions

(Document as action–response pairs demonstrating skilled clinical reasoning.)

Technique Coaching

• Action: [What was demonstrated; errors observed; cues provided; modifications trialed]
  Response: [Patient performance after coaching; accuracy improvement; ability to self-cue]
• [Additional technique coaching as applicable]

Behavior-Change Coaching

• Action: [Barrier problem-solving performed; adherence strategies selected such as reminder plans, habit stacking, environmental changes]
  Response: [Patient-selected strategy; commitment statement; anticipated obstacles discussed]
• [Additional behavior-change coaching as applicable]

Education

• Action: [Rationale explained; safety guidance or stop-sign symptoms reviewed; materials provided with version/date]
  Response: [Teach-back result; remaining questions or confusion]

Clinical Observations

(Brief indicators relevant to therapy targets. If not assessed during this contact, state "Not assessed—reason.")

• Objective: [Lip seal consistency, tongue resting posture, nasal breathing tolerance, swallow pattern, or other findings; include source such as in-session assessment or video review]
• Subjective: [Patient-reported symptoms such as mouth dryness on waking, snoring reports, daytime fatigue]

OSA Therapy Adherence

(Include only if OSA therapy is part of active care and relevant adherence data is available; otherwise omit this subsection entirely.)

• Therapy type: [positive airway pressure / oral appliance / positional therapy]
• Measurement period: [Date range]
• Data source: [Objective device download / Self-report] (Specify device/platform if objective.)
• Key metrics: [Average hours per night; percentage of nights used; other relevant metrics]
• Troubleshooting or coordination: [Issues addressed; referrals or communication with other providers]

Plan Updates

• Home program status: [Continue as prescribed / Modify / Pause] — [Rationale based on adherence, barriers, and clinical observations]
• Specific changes: [Old dose/frequency → New dose/frequency; technique cues updated; exercises added or removed] (Use explicit old-to-new phrasing. State "No changes" if continuing as prescribed.)
• Adherence goal for next period: [Quantified goal, e.g., ≥80% of prescribed sessions]
• Tracking method for next period: [Tool or method; verification plan]
• Next follow-up: [Timing, modality, and purpose]