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Run: Target Behavior Identification and Tracking Form

Track a resident’s target behavior, triggers, impact, and follow-up actions in one clinical form built for psychotropic medication documentation and review.

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Documentation Overview

Resident Identifier (required)

Enter the resident's internal identifier or chart number. Avoid collecting unnecessary PII.

Documentation Date (required)

Date this target behavior tracking form is completed.

Documented By (required)

Name and role of the staff member completing this form.

Reason for Tracking (required)

Select the primary reason the behavior is being tracked.

Other Reason

Provide a brief explanation if 'Other' was selected.

Tracking Start Date (required)

Date the target behavior baseline tracking begins.

Target Behavior Definition

Behavior Category (required)

Select all categories that apply to the target behavior.

Objective Behavior Description (required)

Describe exactly what the resident does, including observable actions, words, and context. Example: 'Hits staff with open hand during bathing assistance.'

Known Triggers or Antecedents

Select known triggers that appear to precede the behavior.

Trigger Details

Describe any trigger not listed above.

Observed Frequency (required)

Number of times the behavior is observed per shift, day, or other defined period.

Frequency Unit (required)

Select the time period used for the frequency count.

Impact and Safety Assessment

Observed Impact (required)

Select all impacts that have been observed.

Impact Details (required)

Describe the specific impact observed and any immediate response required.

Did injury or harm occur? (required)

Injury or Harm Details

Document the nature of the injury or harm, including who was affected and what intervention was provided.

Baseline Tracking and Follow-Up

Baseline Measurement Method (required)

Select how the behavior will be measured during baseline tracking.

Baseline Tracking Duration (Days) (required)

Number of days planned for baseline tracking before review.

Follow-Up Review Date (required)

Date the care team will review the tracked behavior and response.

Planned Follow-Up Action (required)

Select the next action after baseline tracking.

Additional Notes

Include any other clinically relevant information needed for the audit trail.

Consent and Submission

PII and Minimum-Necessary Notice Acknowledged (required)

I understand this form collects only the minimum necessary information for clinical documentation and audit trail purposes.

Yes No N/A

Information Accuracy Confirmed (required)

I confirm the information entered is accurate to the best of my knowledge.

Yes No N/A

Submission Attestation (required)

Electronic attestation by the staff member submitting this form.

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