Progress Report (Myofunctional Therapy)

Note Type: Progress Report – Myofunctional Therapy

Reporting Period: [start date] to [end date]

Date Written: [date]

Patient: [full name or identifier]

DOB: [date of birth]

Provider: [name, credentials]

Visits This Period: [number of treatment sessions; note cancellations/no-shows if relevant]

Setting: [outpatient clinic / telepractice / home health]

Diagnoses: [primary diagnosis and treating problem; include pertinent comorbidities affecting progress]

Functional Impact: [1–2 sentences linking orofacial dysfunction to functional consequences]

Subjective

[Patient/caregiver reported changes since last report] (Use clear attribution such as "patient reports" or "caregiver reports." Include reported changes in symptoms, function, or oral habits. Do not infer beyond what is explicitly stated.)

[Home program adherence as reported, including frequency, barriers, and any objective evidence such as logs] (Do not infer adherence if not explicitly reported.)

Objective

Baseline Anchor: Baseline evaluation date: [date]. Key baseline indicators tied to current goals:

• [Indicator]: Baseline ([date]): [value] → Prior report ([date]): [value] → Current: [value]
• [Indicator]: Baseline: [value] → Prior report: [value] → Current: [value]

(Include 2–5 key indicators. Use compact longitudinal format to show change over time.)

Standardized measures this period: [measure name, baseline score, current score, change] (Include only measures actually readministered; prioritize validated tools.)

Clinical observations: [pertinent findings tied to active goals, including oral rest posture, breathing mode, swallow pattern, and relevant motor observations as applicable] (Use operational definitions and quantify when possible. Omit findings not tied to goals.)

Task performance: [goal area, task conditions, cueing level, accuracy, and carryover indicators] (Sample major goal areas; specify conditions and quantify performance.)

Goal Progress

(Report status for each active goal using stable identifiers maintained across the episode. If progress is limited, document reasons and planned adjustments.)

• [Goal ID]: [goal text or label]
  Status: [Met / Partially Met / Progressing / Not Met / Discontinued / On Hold]
  Evidence: [specific, quantified indicators of change]
  Decision: [continue / modify / discontinue; specify adjustments if applicable]
• [Goal ID]: [goal text or label]
  Status: [status]
  Evidence: [evidence]
  Decision: [decision]

Assessment

[Summary of measurable improvement toward goals, citing strongest objective indicators] (Do not introduce new subjective information.)

Skilled need rationale: [why ongoing skilled intervention is required—e.g., movement pattern analysis, individualized cueing, progression decisions, safety considerations, or complexity factors]

Prognosis: [good / fair / guarded] with [expected trajectory and criteria for discharge or transition to independent program] (If maintenance-focused, state why skilled care is needed to maintain function or prevent decline.)

Plan

Plan decision: [Continue with modifications / Continue unchanged / Hold / Discharge]

Frequency/duration: [sessions per week] for [number] [weeks/visits]

Goal updates: [added / modified / discontinued goals with identifiers] (Omit if no changes.)

Home program: [updated exercises, frequency, self-monitoring expectations]

Coordination/referrals: [disciplines and purposes if indicated] (Omit if none.)

Safety/adverse events: [document if present; otherwise omit this line]

Provider Signature and Credentials: [signature and credentials]

Date/Time Signed: [date and time]