Myofunctional Therapy Treatment Session Note (SOAP)

Date of Service: [Date of service]

Patient: [Patient name]

Clinician: [Clinician name, credentials]

Treatment Time: [Total minutes]

Diagnosis/POC Reference: [Diagnosis and/or Plan of Care reference]

Subjective

[Patient/caregiver report on HEP adherence including estimated frequency and any barriers] [Current symptoms or tolerance issues relevant to OMT] [Pertinent interval changes since last visit]

(2–4 sentences using reporting language such as "reports" or "states." Include only elements relevant to this visit. If HEP adherence is unknown, briefly state why. Omit categories that do not apply.)

Objective

(Document each intervention addressed using the format below. Omit interventions not addressed. If a clinically expected element was intentionally deferred, briefly note the reason.)

• [POC Goal: [goal number/name]; Intervention: [exercise/task]; Dosage: [sets × reps or duration]; Outcome: [accuracy %, duration, or quality descriptor]; Cues: [Independent / Min / Mod / Max] [verbal / visual / tactile / biofeedback]; Modifications: [progression, regression, or support changes]; Comparison: [vs. prior session if meaningful]]
• (Repeat for each intervention addressed)
• Education: [Topics addressed]; Teach-back: [confirmed / not confirmed] (Include only if education provided)
• HEP: [Reviewed / updated with changes noted] (Include only if addressed)

Assessment

[Patient response to session and tolerance] [Progress toward POC goals with objective anchors] [Clinical reasoning for skilled myofunctional therapy this session] [Barriers or limiting factors affecting progress]

(3–6 sentences synthesizing clinical interpretation. Do not simply restate objective findings. Address why skilled intervention was required, such as ongoing cueing needs, task modification, or clinical judgment.)

Plan

• Next session focus: [1–3 prioritized targets]
• HEP update: [Exercise names, dosage, frequency, and quality cues]; Handout provided: [yes / no]
• POC status: [Continue current POC / Anticipate frequency or duration change with rationale]
• Coordination: [Planned communication with referring provider or specialist and purpose] (Omit if none)

Clinician Signature: [Signature, credentials, date]