Sleep-Disordered Breathing/OSA Myofunctional Therapy Note

Date of Service: [Date]

Patient: [Full name and identifiers per policy]

Encounter Type: [Initial Evaluation / Follow-up / Progress Report / Discharge]

Clinician: [Name, credentials]

Referring Provider: [Name, specialty]

Diagnosis: [Confirmed OSA / Suspected OSA / Other sleep-disordered breathing] (If confirmed, include sleep study type, date, and severity metrics when available.)

Subjective

Chief Concern: [Primary reason for visit in one concise line] (Align with episode goals; include brief patient quote only if provided.)

Interval History: [Changes since last visit or baseline presentation for initials] (Include sleep-related symptoms, current SDB treatment context such as PAP or oral appliance status and tolerance, and relevant contextual factors. Attribute bed-partner observations when used.)

OMT Adherence: [Home exercise adherence details] (For follow-up and progress visits: specify days/week, minutes/session, exercises completed vs skipped, barriers encountered. Distinguish self-report from objective log data.)

Patient-Reported Outcomes: [Instrument name, score, date, and baseline comparator] (If PROs not collected, briefly state reason.)

Safety: [Drowsy driving or occupational safety concerns and counseling provided] (Omit if none present.)

Objective

Exam: [Relevant orofacial observations] (Include resting lip and tongue posture, nasal breathing adequacy, tongue mobility and strength, and findings affecting exercise tolerance such as TMJ symptoms or oral dryness. Document functional impact; defer medical or dental diagnoses to appropriate clinicians.)

Therapy Session: [Exercises trained, dose delivered, technique quality, modifications, and patient response] (Include for treatment visits; use protocol-consistent exercise names; specify sets, reps, hold times, and cueing level required.)

Device Data: [Device type, usage metrics with date range, and data source] (Include only if PAP or oral appliance data is available; specify whether from device download, app, or patient report.)

Assessment

[Concise clinical synthesis] (State working problem with severity data if known; summarize response to OMT including symptom and PRO trends; identify key contributors or barriers such as adherence, technique fidelity, or nasal obstruction; note safety risks if present. Use "suspected OSA" when sleep testing has not been completed; do not diagnose OSA based on screening tools or symptoms alone.)

Plan

OMT Protocol: [Protocol phase, home program dose and frequency, technique emphasis, progression or regression guidance, materials provided]

Care Coordination: [Recipients, content to communicate, method and timing, patient consent status] (Include when communication with sleep physician, dental sleep clinician, ENT, or other providers is planned.)

Follow-up: [Next visit interval and focus] (Note if progress report or discharge is approaching.)

Total Treatment Time: [Minutes] (Include only if required for billing.)