Long-Term Care Behavioral Health Progress Note (SNF/ALF)

Resident: [name, DOB, MRN/facility ID]

Facility/Unit: [SNF or ALF name, unit, room]

Date/Time of Service: [date; start–stop or total time per facility requirement]

Author: [name, credentials, discipline]

Encounter Type: [follow-up BH progress note; [in-person / telehealth]; [individual / collateral-only]]

Participants: [resident; staff roles present; family/POA; interpreter if any]

Reason for Visit: [routine follow-up / post-incident / post-med change / staff request / care plan review]

Interval Summary

[Interval summary] (2–4 sentences. State clinical focus for today's visit; interval changes since last BH contact with dates; new triggers/stressors and relevant medical factors; resident engagement level. Specify data sources briefly. If no meaningful change, state so with one objective anchor. If resident unavailable, label as collateral-only and document outreach attempts.)

Target Behaviors & Progress

Behavior: [operational definition—how staff recognize it] (Use observable, nonjudgmental descriptors.)

Frequency/Trend: [count per shift/day/week with look-back window; compared to baseline; data source] (If exact counts unavailable, provide best approximation with source; do not invent quantitative data.)

Context: [time of day; location; care tasks; identified triggers]

Impact: [distress to resident; risk to others; interference with care]

Goal Status: [progressing / plateau / worsening] — [brief rationale]

(Repeat block for each active target behavior. Omit section only if no active behavior plan or BH treatment goals exist.)

Interventions & Staff Coaching

(List specific, observable actions. Always include at least one intervention. Avoid vague entries like "support provided.")

• Intervention: [type/modality] — [content focus] — [adaptations for cognitive/sensory impairment if applicable]. Response: [one concrete indicator].
• Staff coaching (if provided): [who—role/shift]; [skill taught and rationale linked to triggers]; [teach-back: yes/no]; [implementation plan].

Assessment

• [Target Behavior 1]: [improved / worse / unchanged] — [one objective anchor]. Maintaining factors: [unmet needs, pain, environmental, caregiver approach]. Barriers: [if any].
• [Target Behavior 2]: [status] — [anchor]. Maintaining factors: [factors]. Barriers: [if any].

Behavioral Observations: [appearance; affect; cooperation; cognition as observed] (Include only when relevant to clinical picture.)

Safety Assessment: [domains assessed: self-harm / aggression / elopement / care refusal] — [findings] (Be explicit about what was assessed. Do not auto-populate negatives unless actually assessed. If resident unable to participate, note collateral screen with limitations.)

Plan

• [Target Behavior 1]: [continue / modify] interventions — [rationale]. Non-pharmacologic strategies: [environmental modifications, staff response plan]. Monitoring: [what data; who collects]. Escalation: [thresholds for notifying provider]. Follow-up: [interval].
• [Target Behavior 2]: [repeat structure as needed]

Psychotropic Medications (if applicable): [target symptoms]; [adverse effects—especially sedation]; [non-pharmacologic strategies in use]; [recommendations to prescriber]; [PRN patterns].

Refusal/Preferences: [document any refusal with alternatives offered]

Care Coordination: [who informed of plan; requests to team]

(If no plan change: "Continue current behavior plan" with rationale and monitoring focus.)

Billing/Time

Service Code/Time: [code and total time if required]

Diagnosis: [billing diagnosis]

(Include only when required by payer or facility.)

Signature: [Author signature with credentials, date/time]

Supervisor Attestation: [if applicable per facility policy]

(Omit inapplicable sections rather than using empty placeholders. Document reason when expected information is missing. Use dates and look-back windows for trends. Keep session content focused on themes and response—avoid detailed process notes. Direct quotes only when they clarify delusional content, requests, refusal rationale, or safety statements.)