How to Write TMS Notes: Documentation Guide for Mental Health Clinicians
Dr. Medeline Yost
Chief Medical Officer, Augustun
Published July 2, 2026
Updated July 2, 2026
On this page
Transcranial magnetic stimulation (TMS) has become a standard option for treatment-resistant depression and other psychiatric conditions. But TMS is not just a procedure — it is a treatment course that spans weeks, with mapping, daily or near-daily sessions, response monitoring, and adverse event tracking. Each step needs clear documentation.
TMS notes must support clinical continuity, device safety requirements, and payer expectations. A note that only says "TMS given, tolerated well" is not enough. Reviewers and collaborating psychiatrists need to see indication, protocol, motor threshold, session parameters, symptom response, and any side effects — especially headache, scalp discomfort, or mood destabilization.
This guide walks through the main TMS documentation types: initial evaluation, mapping/motor threshold, treatment session notes, and response assessments. For general psychiatric intake structure, see our psychiatric intake note guide.
Why TMS Documentation Matters
TMS documentation serves three audiences at once: the treating team tracking response over 20–36 sessions, the device and safety record for regulatory and quality review, and payers requiring evidence of medical necessity. Incomplete notes create denials, care gaps between the TMS technician and prescribing psychiatrist, and risk if adverse events are not clearly recorded.
- Confirm indication and failed prior treatments (often antidepressant trials).
- Document contraindications screening: seizure history, implanted devices, skull defects.
- Record motor threshold determination and coil placement at each relevant visit.
- Track session number, stimulation parameters, and patient tolerance.
- Monitor PHQ-9 or other rating scales across the treatment course.
- Document adverse events and clinician response in real time.
TMS Note Types Across the Treatment Course
| Note type | When written | Key elements |
|---|---|---|
| Initial TMS evaluation | Before treatment start | Diagnosis, treatment history, contraindication screen, informed consent, treatment plan. |
| Mapping / motor threshold | Day 1 (and when re-mapping needed) | Motor threshold %, coil position, hemisphere, resting motor threshold method. |
| Treatment session | Each session | Session #, parameters, tolerance, side effects, patient mental status. |
| Mid-course review | Around sessions 10–15 | Symptom trajectory, scale scores, protocol adjustment, continue/discontinue decision. |
| Completion / taper | End of acute course | Total sessions, response summary, maintenance plan, relapse precautions. |
Example: TMS Treatment Session Note
TMS Session Note — Session 12 of 36
- Subjective
- Patient reports mild improvement in energy and concentration since session 8. Sleep still fragmented. Denies suicidal ideation. Reports intermittent scalp discomfort after sessions, rated 3/10, resolving within 1 hour. No seizures, syncope, or mood elevation concerns.
- Objective
- PHQ-9 today: 12 (baseline 22). Mental status: cooperative, mildly dysphoric affect, linear thought process, no psychosis. TMS session completed per protocol. Motor threshold 42% of machine output, unchanged from prior mapping.
- Assessment
- Major depressive disorder, partial response to TMS at session 12. Treatment tolerated with mild localized scalp discomfort. No safety concerns today.
- Plan
- Continue daily left dorsolateral prefrontal cortex TMS per established protocol (session 12/36). Continue current antidepressant regimen. Reassess PHQ-9 at session 15. Patient instructed to report worsening mood, mania symptoms, seizures, or severe headache. Next session scheduled.
Example: TMS Mapping and Motor Threshold Note
TMS Motor Threshold Determination
- Subjective
- Patient presents for TMS mapping prior to initiating treatment course. Reports chronic depression with poor response to two adequate antidepressant trials. Denies seizure history, implanted metallic devices, or skull surgery.
- Objective
- Contraindication screen negative. Resting motor threshold identified at 38% machine output using visible thumb twitch method. Left DLPFC treatment site marked 5.5 cm anterior to motor cortex site along sagittal plane. Patient tolerated mapping without adverse events.
- Assessment
- Treatment-resistant major depressive disorder. Cleared for TMS initiation. Motor threshold established.
- Plan
- Begin acute TMS course at 120% resting motor threshold per protocol. Educated patient on common side effects (headache, scalp discomfort) and rare seizure risk. Obtain signed consent on file. Schedule daily treatment sessions.
Documentation Tips for TMS Programs
- 1Use session counters consistently (e.g., "Session 12 of 36") in every treatment note.
- 2Record stimulation parameters when your protocol or payer requires them.
- 3Track rating scales at baseline, mid-course, and end — not only at intake.
- 4Document adverse events the same day, with action taken.
- 5Clarify roles: technician session log vs. physician oversight note when both are required.
- 6Link TMS notes to the broader psychiatric treatment plan and medication list.
An AI medical scribe can reduce the documentation burden for TMS practices by drafting session notes from the clinical conversation while preserving protocol-specific fields. The clinician must verify motor threshold values, session parameters, and safety documentation before signing. Tools like Augustun for psychiatry support structured psychiatric notes that can be adapted for TMS workflows.
AI-Powered · HIPAA-Ready
Streamline TMS and psychiatry documentation
Augustun drafts structured psychiatric notes from in-person and telehealth visits — including intake, progress, and procedure-adjacent documentation. Compare tools in our [best AI scribe for psychiatry](/blog/best-ai-scribe-for-psychiatry) guide.
No credit card required.
Frequently asked questions
What should every TMS session note include?
At minimum: session number, treatment protocol reference, patient-reported symptoms and side effects, mental status or scale scores when tracked, tolerance, and plan for the next session. Many programs also document motor threshold and stimulation parameters.
Who signs TMS documentation?
This varies by setting. Often a psychiatrist or TMS-certified prescriber signs oversight notes while technicians document session delivery. Follow your state, facility, and payer rules for scope and cosignature.
How is TMS documentation different from regular therapy notes?
TMS notes must track a device-based treatment course with mapping, session parameters, and adverse event monitoring — not just psychotherapy content. Many programs use SOAP for medical oversight and separate technician logs for each session.
AI-Powered · HIPAA-Ready
Spend more time with patients, not paperwork.
Augustun transforms ambient speech into accurate notes — finished before your next session.
No credit card required.
Dr. Medeline Yost
Chief Medical Officer, Augustun
Dr. Medeline Yost is an Internal Medicine physician and an emerging leader in clinical innovation. As Chief Medical Officer at Augustun, she helps shape AI-powered tools that streamline clinical documentation and support physicians in delivering higher-quality care. Her professional interests include medical education, workflow redesign, and the responsible use of AI in healthcare — building systems that let clinicians spend more time with patients and less on administrative tasks.