Sleep Medicine Follow-Up Note (Insomnia Management)

Date: [Date]

Provider: [Provider name and credentials]

Encounter Type: [in-person / video / phone]

Visit Reason: Sleep medicine follow-up—insomnia management

Interval History

[Narrative summary of interval since last visit, including time since last visit, interventions prescribed at last visit such as sleep window times, stimulus control rules, and medications, and global response] (Use patient-reported language. Do not infer adherence, benefit, or adverse effects without explicit patient report or diary data. Include key anchor metrics if available such as ISI score change and sleep efficiency trend.)

[Adherence and barriers to sleep window, stimulus control, and medications] (Note specific barriers if present. If not obtained, document as "Not obtained: [reason]. Plan to obtain at next visit.")

[New or worsening issues since last visit] (Include daytime sleepiness, near-miss driving incidents, mood changes, new medications, or schedule disruptions if explicitly reported.)

Sleep Diary Summary: [Source, date range, and number of nights captured; average TIB, TST, SE, SOL, and WASO] (Provide 1–3 sentence clinician interpretation identifying dominant insomnia pattern and how it informs the next CBT-I adjustment. If diary not available, state "Not obtained: [reason]. Plan: [method to obtain before next visit].")

Objective

Vitals/Exam: [Pertinent findings only—BMI if relevant to OSA risk, general appearance, alertness, affect] (Omit multi-system exam unless medically indicated.)

Data Reviewed: [Relevant prior sleep study results, questionnaire scores with dates, pertinent labs if applicable] (Include only results explicitly available today.)

Assessment

• Chronic Insomnia Disorder: [Severity, trajectory since last visit, key perpetuating factors such as conditioned arousal, schedule irregularity, or medication contributors] (Include severity anchors if available, e.g., ISI score or diary-based SE.)
• [Other active problems: suspected/confirmed OSA, RLS, mood or anxiety disorder, long-term hypnotic use] (Include only if applicable. Note interaction with insomnia and implications for management.)

Plan

CBT-I Prescription:

• Sleep window: [Prescribed bedtime] to [fixed wake time], total TIB [X hours]
• Stimulus control: [Key rules emphasized this visit—bed for sleep only, leave bed if awake >15–20 min, consistent rise time, nap restrictions]
• Adjustment rule: [TIB adjustment plan based on SE threshold for next review]
• Safety: [Drowsy driving precautions and contingency plan for excessive daytime sleepiness]

Medications: [Continue / adjust / taper with medication name, dose, timing, and rationale] (If tapering, provide schedule and counsel on rebound insomnia. For sedatives, document safety counseling regarding next-day impairment, complex sleep behaviors, and CNS depressant interactions.)

Comorbidity Work-up: [Sleep apnea testing, RLS labs, behavioral health referral as indicated] (Include only if explicitly planned this visit.)

Relapse Prevention: [Patient-specific early warning signs, maintenance behaviors to continue, step-up plan for flare-ups] (Include only if patient is improving or stable.)

Follow-up: [Timeframe and purpose; what to bring such as completed diary or updated ISI]

Return Precautions: [Severe sleepiness with driving risk, new parasomnias, worsening mood or suicidal ideation, falls, medication adverse events]

(If clinically material information is missing, document "Not obtained" with reason and plan to obtain. Omit billing and time attestations unless explicitly dictated.)