Gut-Directed Hypnotherapy Session Note (IBS)

Date of Service: [Date of service]

Session Time: [Start–stop time or total face-to-face minutes]

Modality: [in-person / telehealth video]

Clinician: [Clinician name, credentials]

Session: [GDH Session number of total planned sessions; protocol name if using structured protocol]

Diagnosis: [IBS subtype: IBS-C / IBS-D / IBS-M / IBS-U / unknown]

Interval History & Symptoms

[Brief narrative capturing reason for today's session and interval course since last visit. Include patient-reported overall trajectory: improved / stable / worsened.] (Use patient-reported language for symptom attributions or triggers. Do not infer causal relationships.)

• Pain: [Severity, frequency, quality/location, functional impact]
• Bowel pattern: [Stool form, frequency, constipation/diarrhea, pattern shifts]
• Urgency: [Presence, frequency, precipitating contexts if reported]
• Bloating: [Severity, frequency, impact]
• Most bothersome symptom: [Patient-identified symptom]

Validated measures: [Measure name, score, and date if administered; otherwise omit]

Alarm features: [No new alarm features reported / New alarm features: GI bleeding, unexplained weight loss, nocturnal symptoms, or severe new pain with actions taken]

Home Practice

• Adherence: [Days/week practiced; minutes per session; modality used]
• Barriers: [Barriers encountered or none reported]
• Perceived benefits: [Patient-reported benefits or none reported]

(If no home practice was assigned or completed, state explicitly with reason.)

Session Intervention

• Pre-hypnosis: [Agenda setting, safety check, rationale reinforcement as applicable]
• Induction/deepening: [Methods used] (Use descriptive tags; avoid verbatim script content.)
• Therapeutic suggestions: [Categories employed: motility normalization / visceral comfort / urgency reduction / pain modulation / bloating relief / gut-calming imagery] (Select all that apply.)
• Imaginal rehearsal: [Scenario addressed or not performed]
• Patient response: [Ease of relaxation, perceived depth, engagement with imagery]
• Adverse reactions: [None observed / description with management steps]
• Post-session state: [Patient state upon conclusion]

Assessment

[Concise synthesis of IBS symptom trajectory anchored to documented measures, response to GDH course to date, current barriers, and brief statement supporting medical necessity for continued sessions.] (Limit to clinical progress and coordination elements; avoid psychotherapy/process content.)

Plan

• Next session: [Date/time; planned focus or protocol component]
• Home practice assignment: [Frequency, duration, specific instructions, troubleshooting guidance]
• Symptom tracking: [Instructions for patient self-monitoring before next visit]
• Care coordination: [Communications with GI, PCP, dietitian, pelvic floor PT] (Include only if applicable.)
• Return precautions: [Instructions to contact clinic or seek urgent care if alarm symptoms develop]

Clinician Signature: [Name, credentials]

Date/Time Signed: [Date and time]

Supervisor Attestation: [Attestation statement; supervisor name and credentials] (Include only if trainee documented the note.)