Biofeedback Therapy Discharge Summary

Biofeedback Therapy Discharge Summary

Patient Name: [Patient name]

MRN: [MRN]

DOB: [DOB]

Authoring Clinician: [Name, credentials, role]

Referring/Ordering Clinician: [Name and role]

Episode Start Date: [Start date]

Discharge Date: [Discharge date]

Reporting Period: [From last progress report date to discharge date]

Primary Diagnosis: [Diagnosis with ICD-10 code]

Secondary Diagnoses: [Diagnoses materially affecting outcomes or self-management] (Omit if none.)

Episode Synopsis

[3–6 sentence narrative summary: referral problem and baseline functional impact; biofeedback modality and training target; total visits completed and adherence pattern; major milestones; outcome headline; discharge disposition] (For urinary incontinence, reference prior pelvic muscle exercise trial and documented failure if present. Do not copy prior HPI verbatim.)

Course of Care

Attendance: [Visits completed] of [visits scheduled] (Note significant cancellations, no-shows, or interruptions only if relevant to outcomes. State "Not documented" if details unavailable.)

Biofeedback Protocol: [Signal type: surface EMG / manometry / HRV-respiration / temperature]; [sensor placement]; [core training targets]; [progression strategy] (Document at the level supported by the record. If specific parameters were not recorded, state this.)

Adjunct Interventions: [Therapeutic exercise, behavioral strategies, patient education methods] (Omit this line if none beyond biofeedback.)

Tolerance/Adverse Events: [No adverse events / Description of adverse events, symptom flares, and protocol modifications]

Outcomes

(Present baseline versus discharge comparison. If baseline was not measured, write "Not assessed at baseline." If discharge testing was not performed, state this explicitly and document clinician observations and patient report, labeled as such.)

Measure	Baseline	Discharge
[Primary symptom frequency/severity or functional metric]	[Value]	[Value]
[Standardized PRO name, if used]	[Score]	[Score]
[Physiologic metric, if collected]	[Value]	[Value]

Goal Attainment:

• [Long-term goal 1]: [Met / Partially Met / Not Met / Not Assessed] (If unmet, state rationale.)
• [Long-term goal 2]: [Met / Partially Met / Not Met / Not Assessed]

Patient-Reported Outcome: [Improvement estimate, confidence in maintaining gains, functional impact statement]

Remaining Deficits: [Persisting symptoms, functional limitations, relapse risk factors] (Omit if none.)

Discharge Plan

Discharge Reason: [goals met / plateau-maximum benefit / transition to another level of care / patient preference / non-attendance / medical contraindication / insurance limitation / lost to follow-up] (If lost to follow-up, include last contact date and outreach attempts.)

Disposition: [independent home program / home program with scheduled follow-up / referral to alternate service (specify) / continued therapy recommended but not completed (reason)]

Home Program:

• Techniques: [Names with purpose]
• Dose: [Frequency, duration, repetitions]
• Equipment: [None / specify]
• Self-monitoring: [Diary / symptom tracker / app]
• Independence verified by: [return demonstration / teach-back] (If not fully independent, specify dependent components.)

Relapse Prevention:

• Early warning signs: [Symptom thresholds and functional changes]
• Self-management steps: [Techniques and dose to resume]
• Escalation pathway: [Who to contact, timeframe]
• Urgent red flags: [List if clinically relevant] (Omit if not applicable.)

(If written relapse plan was not developed, state briefly.)

Follow-Up Recommendations: [Clinician/specialist] for [reason]. Re-referral triggers: [specific thresholds aligned with relapse prevention plan]

Care Coordination

Summary Distribution: [Recipients] via [method]

Patient Education: [Patient received discharge instructions and home program] (Note interpreter services if used.)

Attestation

This document is the discharge/end-of-episode summary covering the reporting period specified above.

Clinician Signature: [Name, credentials] Date: [Signature date]