Plan of Care (Myofunctional Therapy)

Document Type: Plan of Care (Myofunctional Therapy)

Patient Name: [Full legal name]

DOB: [Date of birth] | MRN: [Medical record number]

Date Created: [Date] | Evaluation Date: [Date]

POC Effective Period: [Start date] through [End date]

Rendering Clinician: [Name, credentials, NPI if applicable, clinic/location]

Referring Provider: [Name, credentials, practice, contact method]

Clinical Context & Problem List

[Referral reason and therapy indication]. [Diagnosis with ICD-10 code, or condition description if diagnosing is outside clinician scope]. [Pertinent contributing factors such as airway/breathing concerns, orthodontic appliances, oral habits, sleep-related symptoms, or comorbidities that affect plan design]. [Baseline functional status summary]. (Include only factors relevant to this case. If required information is not available, use "Pending—must be completed prior to initiating treatment.")

1. [Problem domain]: [Observable impairment or behavior pattern] — Baseline: [Measurable status] — Functional impact: [One-line impact statement].
2. [Problem domain]: [Observable impairment or behavior pattern] — Baseline: [Measurable status] — Functional impact: [One-line impact statement].

(Add or remove problem entries as needed. Common myofunctional domains: resting posture [tongue/lips/jaw], breathing pattern, swallow pattern, mastication, oral habits, orofacial coordination. Include only problems supported by evaluation.)

Baseline Measures

Domain	Baseline	Measurement Method	Date
[Domain]	[Baseline value with units/criteria]	[Reproducible method/instrument]	[Date obtained]
[Domain]	[Baseline value with units/criteria]	[Reproducible method/instrument]	[Date obtained]

(Add rows as needed. If a baseline could not be captured, document reason and plan to obtain by a specific visit.)

Goals

(Use stable identifiers [LTG-1, STG-1a] for reference in progress notes. All goals must be measurable and time-bound.)

Long-Term Goals

• LTG-1: [Target behavior/outcome] — Criteria: [Percent accuracy / duration / frequency / cueing level / context] — Timeframe: [X weeks/months] — Generalization: [Clinic / home / functional settings].

• LTG-2: [Target behavior/outcome] — Criteria: [Percent accuracy / duration / frequency / cueing level / context] — Timeframe: [X weeks/months] — Generalization: [Context].

Short-Term Goals

• STG-1a → LTG-1: [Intermediate target] — Criteria: [Percent accuracy / duration / frequency / cueing level / context] — Timeframe: [X sessions/weeks].

• STG-1b → LTG-1: [Intermediate target] — Criteria: [Percent accuracy / duration / frequency / cueing level / context] — Timeframe: [X sessions/weeks].

• STG-2a → LTG-2: [Intermediate target] — Criteria: [Percent accuracy / duration / frequency / cueing level / context] — Timeframe: [X sessions/weeks].

Discharge Criteria

• All LTGs met with maintained performance in functional settings
• Functional plateau reached with documented clinical rationale
• Non-adherence prevents benefit despite documented barrier-addressing attempts
• Medical/dental/ENT intervention needed prior to further progress
• Patient preference or withdrawal from care

Planned Interventions

(List only interventions within scope and supported by evaluation findings.)

• [Problem domain]:
  • [Intervention strategy/technique]
  • [Intervention strategy/technique]
• [Problem domain]:
  • [Intervention strategy/technique]
  • [Intervention strategy/technique]
• Patient/caregiver education:
  • [Education topics with teach-back]
  • [Instructional materials provided]
• Equipment/Materials: [Mirrors / tactile tools / exercise handouts / tracking logs / other]

(Common myofunctional intervention categories: orofacial myofunctional re-education, breathing pattern retraining, swallow pattern training, habit elimination strategies, orofacial coordination exercises, care coordination with dental/ENT/sleep providers.)

Frequency & Duration

Frequency	Duration	Anticipated Visits	Progress Review Target
[Sessions per week]	[Number of weeks or total sessions]	[Expected total visits for this POC]	[Planned re-evaluation date/timeframe]

Home Program

• Program components: [Exercise names/steps aligned to problem domains]
• Expected dosage: [Minutes/day or sets/reps, days/week]
• Quality criteria: [Correct performance description and common errors to avoid]
• Monitoring method: [Paper log / app tracking / caregiver sign-off]
• Safety/stop rules: [Stop for pain, dizziness, or adverse symptoms; report to clinician]
• Caregiver role: [Supervision/prompts/environment setup] (if applicable)
• Teach-back completed: [Y / N] | Date: [Date]

(If home program is not appropriate, document explicit rationale and alternative approach.)

Authorization & Certification

Prior Authorization: Required [Y / N] | Auth #: [Number] | Approved visits/units: [Number] | Auth period: [Dates]

Order/Referral on File: [Y / N] | Order date: [Date]

POC Transmitted to Referring Provider: [Y / N] | Date: [Date] | Method: [Fax / portal / email] | Confirmation: [Reference number]

Certification Method: [Signed POC / Signed order-referral per Jan 2025 rule / Verbal order]

Certification Date: [Date]

Recertification Due: [Date]

(Per CMS rules effective Jan 1, 2025, for therapist-established plans, a signed/dated order or referral may substitute for physician/NPP signature on initial certification if the order is in the record and there is evidence the plan was delivered to the referring provider within 30 days of evaluation.)

Care Coordination

(Include only if interdisciplinary coordination is required; otherwise omit this section.)

Recipient (Name/Role)	Purpose	Method	Timing	ROI Status
[Name, discipline]	[Purpose of communication]	[Phone / fax / portal / email]	[Planned timing]	[On file Y/N]

Signatures

Establishing Clinician:
Signature: _________________ Printed Name: _________________ Credentials: _____ Date/Time: _________

Certifying Provider: (if required)
Signature: _________________ Printed Name: _________________ Credentials: _____ Date: _________

(Ensure signatures are legible or accompanied by printed name. Electronic signatures must be visible on print/export.)

Amendments

(Append dated entries when plan is modified; do not overwrite original content.)

• [Date/Time]: [Summary of changes] — Rationale: [Clinical rationale] — Author: [Name, credentials] — Transmitted to Referring Provider: [Y / N], [Date/Method if applicable].

(For required elements not yet available—diagnosis, goals, frequency/duration, signature—enter "Pending—must be completed prior to initiating treatment." For optional elements or planned assessments, use "Not assessed" with plan to obtain.)