Sleep Health Coaching Note

Date: [Date]

Visit Type: [initial intake / follow-up / brief check-in]

Participants: [Patient; others present if relevant]

Chief Concern & Goals

[Primary sleep complaint in one sentence, optionally incorporating a brief patient quote]

Goals: [Patient-stated outcome goals (how they want to feel/function) and behavior goals (observable targets like schedule changes)] (Distinguish outcome from behavior goals when both are present.)

Sleep History

[For follow-up: interval changes and adherence summary since last visit] (Include only for follow-up visits. Summarize adherence to prior plan, barriers, and improvements or setbacks.)

[HPI narrative: onset, current pattern (initiation/maintenance/early awakening/hypersomnolence), frequency, duration, and daytime impact on alertness, mood, cognition, and functioning] (Synthesize into a coherent paragraph.)

Sleep Schedule: [Bedtime, estimated sleep onset latency, awakenings, wake time, naps; note workday vs. non-workday variability when relevant]

Behavioral Contributors: [Pertinent factors: caffeine/alcohol timing, screen use, bed-use habits, exercise timing] (Include only what is relevant to this patient.)

Medical/Psychiatric/Medication Factors: [Relevant conditions, symptoms, or medications impacting sleep] (Include only if applicable. Avoid assigning diagnoses.)

Screening Findings: [OSA risk features, restless legs symptoms, circadian mismatch indicators, questionnaire scores with instrument name] (Include when clinically indicated. Use risk language such as "features concerning for OSA" rather than diagnostic labels.)

Objective Data

(Include only if obtained. If telehealth or exam not performed, state briefly.)

Vitals: [Relevant vitals including weight, BMI, neck circumference if part of OSA workflow]

Exam: [Pertinent positive findings only] (State "Not performed" or "Telehealth visit" if applicable.)

Sleep Diary/Wearable Review: [Data source, date range, derived metrics (average TIB, TST, sleep efficiency), schedule variability, data quality notes] (Label calculated metrics as derived. Include only if reviewed.)

Assessment

[One-sentence clinical summary linking primary complaint to key drivers and noting any safety or referral flags] (Use risk-stratifying language. Do not assign diagnoses unless credentialed and performing diagnostic evaluation.)

Problems: [For each sleep problem: name (descriptive, non-diagnostic), status (new/ongoing, improving/worsening), key contributing factors, safety risk level when elevated, contraindications or adaptation needs for behavioral interventions] (Repeat for each distinct issue. Note drowsy driving, fall risk, or parasomnia injury risk when present.)

Plan

(Organize by problem when multiple issues present. Include only elements discussed or implemented.)

Behavioral Interventions: [Schedule stabilization with target wake time, stimulus control instructions, sleep restriction parameters with safety screening if applicable, relaxation techniques taught, 1-3 targeted sleep hygiene priorities specific to this case] (Avoid generic checklists.)

Tracking: [Diary/app method, review cadence, troubleshooting guidance for missed entries]

Safety Counseling: [Drowsy driving counseling, fall precautions] (Document when provided. If sleepiness present and not assessed, document explicitly.)

Referrals/Escalation: [Triggers identified (high OSA risk, parasomnia with injury risk, refractory symptoms), actions taken, patient decision if declined] (Include only if applicable.)

Shared Decision-Making: [Options discussed, patient preferences and constraints] (Include when multiple reasonable options were discussed.)

Follow-up: [Interval, homework assignments, next-visit agenda]