Pre/Post-Frenectomy Myofunctional Therapy Note

Identifiers

Patient: [Full name] | Date of Service: [YYYY-MM-DD] | Time: [Start–End or Total minutes] | Location: [clinic / telehealth / home / school] | Visit Type: [Evaluation / Treatment / Progress Report / Discharge]
Provider: [Name, credentials] | Supervising Clinician: [Name, credentials / N/A]
Procedure Status: [Planned / Completed / Not planned / Unknown—records requested] | Site(s): [lingual / labial / buccal] | Procedure Date: [YYYY-MM-DD] | Post-op Day: [#] | Surgeon/Dentist: [Name]

Sources reviewed: [surgeon instructions / operative note / referral / prior therapy notes / patient-caregiver report] (List only sources actually reviewed.)

(Scope: This note documents SLP/OMT therapy services only. Attribute any procedure-related details to their source. Document observed restriction and functional impact without diagnostic labels or statements about adequacy of release.)

Visit Purpose

[Pre- or post-frenectomy myofunctional therapy] addressing [relevant functional domains]. Today's focus: [baseline readiness / immediate post-op gentle ROM / surgeon-directed scar-adjacent mobility / functional carryover]. [Brief patient/caregiver quote if meaningful.]

Subjective

[Patient/caregiver report of functional status since last session, including relevant domains: feeding, swallow, speech, breathing/sleep, rest posture, pain/post-op concerns as applicable. For post-procedure visits, emphasize pain tolerance, tissue tolerance, and any adverse events with source attribution.]

Home program adherence: [Exercises performed, frequency vs. prescribed, barriers encountered, solutions tried]

Interval updates: [New appliances, specialist visits, medication changes, illness—include dates and sources]

Objective

(Document observations without diagnostic labels. If measurement not possible, state why and describe proxy observation used.)

Orofacial Exam: [Observed structures—lips, jaw, tongue, palate, mucosa—noting restriction, blanching, tethering with movement, and functional impact without diagnostic labels]

Function: [Rest posture, breathing mode, swallow/feeding patterns, speech screening as relevant. Note compensations: jaw hiking, lip tension, neck recruitment, head extension, tongue thrust, audible clicking]

ROM/Mobility: [At least one reproducible measure—elevation, lateralization, protrusion, cupping, dissociation, endurance as relevant] | [Pain-limited / mechanically limited] | [Change vs. baseline or prior session]

Wound/Tissue Status: [Color, edema, granulation, exudate, bleeding, tissue tolerance to ROM/touch] | [Actions taken if concerning findings] (Post-procedure only. Use "concerning for" language; do not definitively label infection or dehiscence.)

Interventions

(Document each skilled service. For post-procedure sessions, note precautions followed.)

• [Intervention type]: [Dose: reps/sets/time] | Cues/modifications: [description] | Precautions: [surgeon instructions followed / wound manipulation avoided / intensity modified] | Response: [performance, fatigue, pain, breaks] | Reasoning: [rationale for progression/regression]
• (Repeat for each distinct intervention.)

Assessment

[2–3 sentence clinical summary: current functional status, change from prior session, most limiting impairments, primary compensations, readiness for progression. Do not opine on surgical adequacy or assign etiologic labels without attribution.]

• ROM status: [Key measures with values and trend]
• Functional impact: [Affected domains with brief evidence]
• Compensations: [Primary maladaptive patterns observed]
• Barriers/Coordination needs: [Adherence barriers, pending records, communication needed]

Plan

Next session: [Frequency/duration] | [Focus areas] | [Progression criteria]

Home Program: (2–6 exercises maximum. Include stop rules. Attribute wound-related tasks to source.)

• [Exercise] — [Method] — [Dose/frequency] — Source: [surgeon instructions / therapist recommendation] — Stop if: [bleeding / escalating pain / distress / oral aversion] — If unable: contact surgeon and therapist
• (Repeat as needed.)
• Teach-back: [Completed / Not completed] | Accurate return demonstration: [Yes / No]

Coordination: [Communication sent to surgeon/ENT/lactation/other: summary and questions] | [Date] | [Response: pending / received] | [Referrals recommended with functional rationale]

Safety escalation reviewed: [Yes / No] (Bleeding, fever, spreading swelling, malodor/discharge, inability to feed/hydrate, severe pain, worsening oral aversion, breathing difficulty.)

Signature

Provider: [Name, credentials] | Signature: [Electronic / Handwritten] | Date/Time: [YYYY-MM-DD HH:MM]

Supervisor attestation: [Name, credentials] | [Statement of review] | [Signature/date] (Include only if applicable.)