Biofeedback Therapy Session Note

Patient: [Patient name]; MRN: [Medical record number]

Date of Service: [Date]

Clinician: [Clinician name], [Credentials]

Session Time: [Start time–Stop time or total minutes]; Timed code treatment minutes: [minutes] (Include only if applicable to billing)

Service Model: [in-person / telehealth]

Primary Indication: [Diagnosis or treatment focus]

Episode Context: Session [number]; Plan of Care: [reference or date]

Biofeedback Consent: [On file / Obtained today] (Include brief note if obtained today or if consent status requires clarification)

Subjective

[Interval symptom changes since last session; home practice adherence including frequency, barriers, and perceived benefit; relevant medication or therapy changes; patient-stated goal for today] (Summarize in a brief paragraph using "Patient reports..." language. If nothing new, state "Patient reports no interval changes.")

Objective

Modality & Setup: [Biofeedback type: SEMG, HRV, thermal, EDA, neurofeedback, pelvic floor EMG, etc.]; [Device/system used]; [Sensor type and anatomical placement]; [Patient position]; Signal quality: [good / fair / poor] with [brief note on artifacts or calibration if relevant]

Session Parameters: [Protocol structure including baseline duration, number of trials or blocks, task conditions]; Feedback type: [visual / auditory / threshold-based / combined]; Targets: [threshold values or goals set]

Skilled Coaching: [Specific cueing, technique instruction, or modifications made during session based on real-time physiologic response] (Document skilled adjustments and clinical reasoning to support medical necessity)

Metrics:

• [Parameter name, units]: Baseline [value]; Training [average, best, or time-in-target]; Post-session [value]
• [Additional parameters as measured] (If a metric was not recorded, note the reason)

Tolerance: [Patient comfort and engagement]; [Any adverse events and actions taken] (Note any factors limiting participation)

Assessment

[Synthesis of response to today's intervention tied to measured data; progress toward treatment goals compared with prior sessions; skill acquisition status including discrimination, self-correction, and independence; clinical rationale for continuing or modifying treatment] (Avoid vague statements; reference specific metrics)

Plan

Next Session: [Planned modality, progression, or new targets]

Home Practice: [Technique]; [Dosage: frequency and duration]; [Tracking method] (If no home practice assigned, document rationale)

Follow-up: [Coordination with other providers or referrals if indicated]

Clinician Signature: [Signature], [Credentials]

Date/Time Signed: [Date and time]

(Include co-signature line only if supervision applies)