Biofeedback Therapy Plan of Care

Patient name: [Patient full name]

DOB: [MM/DD/YYYY]

MRN: [Medical record number]

Date established: [MM/DD/YYYY]

Author: [Name, discipline, credentials]

Setting/Location: [Clinic/program/telehealth location]

Episode start date: [MM/DD/YYYY]

Anticipated end date: [MM/DD/YYYY / TBD]

Visit number: [Visit # / Unknown]

Referring clinician: [Name, credentials, contact / Unknown/not provided]

Clinical Indication & Treatment Rationale

(Establish medical necessity. Do not infer diagnoses from modality.)

• Primary diagnosis: [Diagnosis] (If unconfirmed: [Working diagnosis]; confirmation plan: [Test/consult expected to confirm])
• Secondary diagnoses/comorbidities affecting treatment: [Relevant conditions and implications for biofeedback training]
• Targeted impairments: [Functional or physiologic impairments being treated]
• Relevant prior interventions and key findings: [Pertinent past treatments, response, and decision-driving test findings]
• Rationale for biofeedback: [Why chosen; alignment of physiologic signal with impairment; expected mechanism of benefit]
• Patient ability to participate: [Cognitive/behavioral readiness, language needs, access considerations]
• Barriers/risks considered: [Potential barriers and mitigation strategies]

Biofeedback Protocol

(Provide enough detail for another clinician to reproduce the setup.)

[Problem 1: Name of treated problem/impairment]

• Modality type: [sEMG / manometry/pressure / thermal / electrodermal / HRV/respiration / neurofeedback / other—specify]
• Target physiologic signal: [Signal and how it reflects the impairment/function targeted]
• Equipment and sensor setup:
  • Device: [Manufacturer/model; relevant settings]
  • Sensors and placement: [Sensor type; anatomic landmarks; laterality; channels]
  • Patient position: [Position for training; supports used]
• Baseline metrics: [Measured values with units and date / To be obtained at first session]
• Training plan:
  • Session structure: [Total session length and active biofeedback training time in minutes]
  • Training tasks: [Down-training / up-training / coordination / pacing / resonance breathing / functional integration—specify]
  • Feedback type: [Visual / auditory / tactile; displays and thresholds used]
  • Progression rules: [Objective criteria to advance or regress training]
  • Transfer/functional practice: [How skills will be applied to real tasks]
• Adjunct components: [Planned education topics; coordination with concurrent interventions; care team communication]

(Repeat subsection for each additional treated problem as needed.)

Dose

(Do not infer from diagnosis.)

• Frequency: [Sessions per week]
• Duration: [Weeks and/or anticipated total visits; e.g., 6–10 sessions, reassess at visit 4 / TBD with criteria to finalize]
• Session length: [Minutes per session]
• Decision checkpoint: [Visit or date for reassessment]

Goals

(Prioritize by safety/medical urgency, then function, then symptom burden and patient preference. Include short-term goals when episode exceeds 2–3 visits.)

LTG1: [Problem addressed]

• Metric: [Physiologic measure / validated scale / diary / functional task]
• Baseline: [Value with units and date / Baseline pending—to be obtained at visit 1]
• Target: [Specific value or change criterion with units]
• Timeframe: [By date or visit number]
• Functional meaning: [Functional relevance or participation impact for patient]

STG1a: [Short-term sub-goal with metric, baseline, target, timeframe]

STG1b: [Additional short-term sub-goal as needed]

LTG2: [Problem addressed]

• Metric: [Physiologic measure / validated scale / diary / functional task]
• Baseline: [Value with units and date / Baseline pending—to be obtained at visit 1]
• Target: [Specific value or change criterion with units]
• Timeframe: [By date or visit number]
• Functional meaning: [Functional relevance or participation impact for patient]

(Add additional LTGs and nested STGs as clinically indicated.)

Outcome Measures & Monitoring

• Selected measures:
  • [Symptom diaries: type, scoring method, frequency]
  • [Validated questionnaires: name, scoring, frequency]
  • [Physiologic measures from biofeedback system: metrics, frequency]
  • [Functional task measures: task description, criteria, frequency]
• Reassessment schedule: [Baseline at visit 1; formal reassessment every X visits; plan review at midpoint and near discharge]
• Response definitions:
  • Adequate response: [Criteria for clinically meaningful progress]
  • Partial response: [Criteria for sub-threshold improvement]
  • Non-response: [Criteria for insufficient change despite adherence]
  • Worsening/adverse response: [Criteria for deterioration or adverse effects]

Home Program

(Include when between-visit practice is expected.)

• Techniques: [Self-regulation/breathing/relaxation/coordination strategies; equipment if needed]
• Dose: [Minutes per day; days per week]
• Progression: [How to increase difficulty safely]
• Adherence monitoring: [Diary / app / device logs / verbal report; review schedule]
• Safety notes: [When to stop, modify, or contact clinic]

Safety Considerations

(Always include this section.)

• Contraindications/precautions: [Modality- and anatomy-specific considerations; infection control for internal sensors if applicable / No contraindications identified; will reassess each visit]
• Patient comfort and safety measures: [Chaperone policy; trauma-informed approach; privacy; consent process; sensor hygiene]
• Escalation thresholds: [Red flags; when to pause treatment; when to contact referring clinician]

Plan Governance

• Scheduled plan review: [Date or visit number]
• Criteria to continue treatment: [Progress toward goals; skill acquisition; adherence; no safety concerns]
• Criteria to modify plan: [Partial response at checkpoint; plateau; new barriers; new findings]
• Criteria for discharge: [Goals met with self-management; maximum benefit reached; patient preference; need for different level of care]
• Discharge deliverables: [Maintenance home program; guidance on when to return; communication to referring clinician]

Authentication

• Signature: _______________________ Date: [MM/DD/YYYY]
• Credentials: [Name, degree(s), license/certification, discipline]
• Order/certification status: [Certified on MM/DD/YYYY / Pending—actions taken and follow-up date]
• Planned communication: [Updates to referring clinician at midpoint and discharge; plan shared with patient: Yes / No]