Maintenance/Retention Visit Note (Myofunctional Therapy)

Date of Service: [Date]

Patient Name: [Full name]

Provider: [Provider name, credentials]

Visit Type: Maintenance/Retention Visit – Myofunctional Therapy

Reason for Visit: [Brief 1-line reason for today's visit]

Interval History

Prior episode context: [Discharge date, time since discharge, and key goals achieved at discharge] (1–2 sentences maximum.)

(Document interval changes in a flowing narrative or short bullets. If a caregiver provides history, note their relationship. For any domain with no changes, state "no interval changes.")

• Symptom and function status: [Changes in rest posture (lips, tongue), breathing pattern (nasal vs mouth; daytime vs sleep), swallow function, orofacial discomfort/tension]
• Adherence: [Home exercises and habit targets performed: frequency, consistency; barriers encountered; facilitators used] (Document neutrally without judgment.)
• Airway and sleep: [Nasal congestion/allergies; snoring; witnessed apneas; daytime sleepiness; ENT interventions; changes to airway devices] (Patient-reported symptoms only.)
• Orthodontic status: [Current phase: active treatment / retention; retainer type and wear schedule; recent changes; upcoming milestones] (If not applicable, state "N/A.")

Objective

(Document clinician observations and measurements from today. Keep entries brief with measured values where possible. Omit vitals unless collected and relevant.)

• Resting posture: Lips: [closed / intermittent / open]; Tongue: [palatal / low / interdental]; Nasal breathing at rest: [yes / no]; [Notes on congestion if present]
• Functional re-checks: Saliva swallow: [tongue thrust present / absent], [compensations]; Water swallow: [single and/or sequential sip findings]; Chewing: [pattern if assessed]
• Lingual mobility: [Elevation, lateralization, and any functional restrictions observed]
• Outcome measure: [Tool name, score, comparison to last score with date] (If no standardized tool used, state "focused clinical re-check only.")

Assessment

[Problem-oriented clinical impression linking findings to relapse risk and maintenance need] (Avoid vague statements like "doing well.")

• Maintenance status: [stable / mild drift / relapse]
• Goal carryover: [Discharge-level goals maintained / partially maintained / not maintained in daily life]
• Relapse risk factors: [Airway instability / orthodontic transitions / adherence barriers / other identified drivers] (If none, state "no active risk factors identified.")
• Skilled need rationale: [Reason continued maintenance services are warranted, e.g., pattern changes, emerging compensations, program redesign needed] (If visit was informational only, state "no skilled intervention indicated.")
• Out-of-scope concerns: [Symptoms or findings requiring referral to other providers] (Only include if applicable.)

Plan

• Home program: [Specific exercises and/or habit targets with frequency and context cues; progressions, regressions, or simplifications based on today's findings]
• Referrals/coordination: [Recommended evaluations (ENT / sleep / orthodontic / other) with reason and urgency; coordination messages sent] (Only include if applicable.)
• Follow-up: [Recommended interval for next visit]; [Criteria for earlier return]; [Criteria for discharge from maintenance if stable]

Provider Signature: [Provider name, credentials, date]

Cosignature: [Supervising provider name, credentials, date] (Only if required.)