Biofeedback Modality Setup/Calibration Note

Date/Time: [Date and time of setup]

Patient: [Full name and identifier]

Author/Credentials: [Name, credentials, role]

Setting: [Outpatient clinic / Inpatient / Home program setup / Other]

Note Type: [Initial Setup / Recalibration / Troubleshooting Re-setup]

Reason for Note: [Brief trigger—new modality, sensor site change, artifact requiring recalibration, device/software change, policy timeline, other]

Indication & Scope

[Clinical indication and target physiologic variable—e.g., sEMG relaxation training for tension headache, HRV coherence for stress management, respiratory pattern retraining for dysfunctional breathing]. Order/plan reference: [Reference or "Not available at time of setup—follow-up required"]. This note documents setup/calibration and patient instruction on signal meaning. Therapeutic interventions are documented in the session note.

Device & Modality

• Modality type: [EMG / HRV / Respiration / Skin conductance / Temperature / EEG / Multimodal]
• Manufacturer & model: [Manufacturer, model]
• Software: [Name, version]
• Protocol/program: [Protocol/program name or "None"]
• Feedback mode(s): [Visual / Auditory / Haptic / Multimodal]
• Device serial/asset #: [Number or "Not tracked per clinic workflow"]

Sensors & Supplies

• Sensor types used: [Surface electrodes / Respiration belt / PPG sensor / Intracavitary probe / Temperature sensor / EDA electrodes / Other]
• Number of channels active: [Number]
• Consumables: [Skin prep materials, conductive gel/paste, adhesives, barriers/sheaths, tape, other]
• Reuse classification & disposition: [Single-use—discarded / Reusable—cleaned and stored per protocol]
• Lot/serial numbers: [Values or "Not tracked per clinic workflow"]

Infection Control & Safety

• Hand hygiene: Performed before patient contact and after equipment handling [Yes / No]
• PPE: Gloves used [Yes / No / N/A]; Other PPE [Specify type or "None required"]
• Skin/mucosa integrity: Intact at sensor sites [Yes / Describe if compromised]; Adhesive/latex sensitivity screened [Yes / No / N/A]
• Equipment disinfection: Intact-skin contact items [Cleaning agent/method or "N/A—single-use"]; Mucous membrane contact items [High-level disinfection method / Disposable barrier used / N/A]
• Disposal: Single-use items discarded appropriately [Yes / N/A]
• Deviations from policy: [None / Describe]

Patient Preparation & Positioning

• Position: [Seated / Supine / Standing / Other]
• Site preparation: [Skin cleaned / Light abrasion / Shaved / Gel applied / Dry prep] (List all performed)
• Draping for sensitive sites: [Describe or "N/A"]
• Chaperone: [Offered and present—name, role / Offered and declined / N/A]

Sensor Site Configuration

(Add or remove rows to match channels used. For sEMG, include electrode orientation and inter-electrode distance in Notes. For intracavitary probes, include probe type, barrier, insertion by patient vs clinician, and tolerance. If site changed during troubleshooting, document original site, reason, and final site.)

Channel	Sensor Type	Anatomical Site & Laterality	Reference/Ground	Fixation Method	Notes
[Ch 1]	[Sensor type]	[Site and laterality]	[Reference/ground location]	[Adhesive / Tape / Strap / Sleeve]	[Orientation, inter-electrode distance, probe details, site changes if any]
[Ch 2]	[Sensor type]	[Site and laterality]	[Reference/ground location]	[Fixation method]	[Notes]
[Ch 3]	[Sensor type]	[Site and laterality]	[Reference/ground location]	[Fixation method]	[Notes]

Signal Quality Verification

• Device functional check: Power/self-check [Passed / Failed—describe]; Cable/lead integrity [Intact / Issue—describe]
• Baseline stability: [Stable / Drifting / Noisy] during initial observation
• Impedance/contact quality: [Values per channel with units] or "Impedance check not available—signal quality assessed by baseline stability and artifact inspection"
• Artifacts observed: [None / Motion / Electrical interference / Poor contact / Sweat / Respiratory movement / Other—describe]
• Mitigation steps: [Re-prepped skin / Repositioned electrodes / Adjusted ground / Added strain relief / Reduced nearby interference / Other] (If applicable)
• Post-mitigation status: [Adequate for training / Marginal—monitor / Inadequate—follow-up required]

Calibration & Threshold Setup

• Calibration performed: [Yes / No / Not applicable]

(If yes, complete the following:)

• Calibration type: [Baseline normalization / Task-based calibration / Gain/offset adjustment / Auto-calibration / Other]
• Patient tasks used: [Describe—e.g., rest-contract-rest sequence, paced breathing at target rate, voluntary contraction/relaxation]
• Filter/settings adjustments: [Filter types and values, smoothing, gain adjustments]
• Final thresholds/targets: [Numeric thresholds or descriptive targets as displayed to patient]
• Troubleshooting: Problem [Describe]; Interventions [List]; Resolution [Resolved / Unresolved—reason and follow-up plan] (If applicable)

Patient Instruction

[Narrative of instruction provided: what each feedback element represents in plain language, how patient should respond to feedback during training, safety education including stop criteria for dizziness/pain/skin irritation. Document teach-back or demonstration—e.g., "Patient correctly restated meaning of signals" or "Demonstrated target relaxation response with visual feedback for 2 minutes."] (Use patient quotes sparingly only to clarify understanding)

Patient Tolerance & Response

• Tolerance of placement: [Well tolerated / Mild discomfort / Significant discomfort—describe]
• Discomfort level: [0–10 or descriptive]
• Skin response post-removal: [Intact / Mild redness / Irritation / Other—describe]
• Anxiety/other responses: [None / Describe]
• Adverse events: [None / Describe event and actions taken]
• Session termination: [Completed as planned / Stopped early—reason and follow-up plan]

Disposition & Plan

• Sensors removed: [Yes / No—reason]
• Settings saved: [Yes / No]; Protocol name: [Name or "N/A"]
• Recalibration criteria: [Sensor site changes / Poor signal quality / Device or software change / Policy timeline / Other]
• Treatment note reference: [Refer to session note for clinical plan—not duplicated here]

Signature

[Author name, credentials, date/time of signature]

(If correction needed later, add clearly labeled addendum with author, date, and time—do not overwrite original entry.)