Hyperbaric Oxygen Therapy (HBOT) Daily Treatment Note

Date of service: [Date]

Treatment times: [Start time] – [End time]

Facility / Chamber: [Facility name] ; [Chamber ID]

Supervising clinician: [Name, credentials]

Patient: [Patient name] | MRN: [MRN] | DOB: [DOB]

Session number: Treatment #[number] of [total planned]

Primary HBOT indication: [Diagnosis] ([ICD-10 code])

Coverage context: [Medicare NCD-covered / commercial policy / N/A] (Include only if relevant to documentation requirements.)

Indication & Continued Medical Necessity

[Brief statement of HBOT indication and why treatment remains appropriate today.] (2–4 sentences. For wound indications, state the eligibility criterion—e.g., Wagner grade, failure of standard wound care. Include attestation: within prescribed course, ongoing objective response, or persistent clinical need. If detailed eligibility documented in a separate same-day note, reference that note.)

• 30-day reassessment tracking: Last formal wound evaluation: [date]; Next due: [date]. (For Medicare wound indications only. If overdue or data unavailable, document explicitly with plan to obtain before continuing treatment.)

Interval History

[Changes since prior HBOT session.] (2–4 sentences. Include: new symptoms affecting HBOT safety—ear/sinus, respiratory, chest pain; relevant medication changes; intercurrent events such as ED visits, procedures, infections; patient-reported tolerance of prior session. If none, state: "No interval changes since prior session.")

Pre-Treatment Assessment

Vitals: Temp [value]; HR [value]; BP [value]; RR [value]; SpO2 [value]% [on room air / on supplemental O2]

Pre-treatment glucose: [Value] mg/dL at [time] (Include for patients with diabetes or hypoglycemia risk; omit for others.)

Focused exam: [Ear exam findings and ability to equalize]; [Pulmonary status]; [Neuro baseline if relevant]; [Wound gross appearance if not formally measured today]

Safety clearance: [Contraindication screening performed and patient cleared for HBOT / NOT cleared pending: reason]. (Do not state cleared unless vitals and safety screening are documented. Note any relative precautions and how addressed.)

Pre-medications: [None / Drug, dose, route, time]

Treatment Delivered

Protocol: [Per active HBOT plan, no changes / Protocol name and any modifications]

Chamber: [Monoplace / Multiplace]; ID: [Chamber ID]

Treatment parameters: Pressure: [value] ATA; Time at depth: [minutes] min; Oxygen delivery: [hood / mask / monoplace chamber]; Air breaks: [number] × [minutes] min each

Interruptions: [None / Interrupted for: reason; duration; resumed yes/no; clinical decision-making]

Supervision attestation: [Supervising clinician evaluated the patient prior to treatment and remained immediately available throughout the session.] Interventions during treatment: [None required / Ear-clearing coaching / Medications ordered / Glucose management / Protocol modified / Treatment aborted: rationale]. (Reflect actual session; do not copy forward from prior notes.)

(For minute-by-minute parameters, see chamber operator log.)

Tolerance & Post-Treatment Status

[Brief statement of overall tolerance—e.g., tolerated well without complications, mild symptoms, or adverse event occurred.]

Adverse events: [None / Event type: ear-sinus barotrauma / oxygen toxicity / hypoglycemia / claustrophobia / pulmonary symptoms / other]; Severity: [grade if applicable]; Interventions: [describe]; Outcome: [resolved / ongoing]; Disposition: [treatment completed / aborted]; Follow-up: [return precautions, referrals] (Include only if adverse event occurred.)

Post-treatment glucose: [Value] mg/dL at [time] (Include for patients with diabetes or hypoglycemia risk; omit otherwise.)

Post-treatment vitals: [Not indicated / Temp; HR; BP; RR; SpO2] (Include if clinically indicated or per facility protocol.)

Wound Status & Objective Response

(For wound indications. For non-wound indications such as CO poisoning or radiation injury, use the Clinical Status & Response section instead and omit this section.)

Wound identification: [Site], [laterality], [etiology/classification—e.g., left plantar DFU, Wagner III] (Do not infer classification without documentation.)

Today's assessment: [If measured: L × W × D in cm; tissue (% granulation / slough / eschar); exudate amount and character; periwound status; infection indicators] / [If not measured: "Last measurement [date]; see wound measurement record"]. Photos: [obtained / not obtained]

Concurrent wound care: [Offloading status]; [Recent debridement—reference procedure note if today]; [Current dressings]; [Infection management]; [Glycemic optimization]; [Vascular status]

Objective response: Baseline at HBOT start ([date]): [L × W × D or surface area]; Current ([date]): [same metrics]; 30-day interval change: [surface area % change, depth change, granulation % change, exudate trend]. (At least one quantitative metric required. If data unavailable or overdue, state reason, last available data with date, and plan to obtain updated measurements.)

Clinical Status & Response

(For non-wound indications—CO poisoning, radiation injury without wound, decompression sickness, etc. Omit if wound indication documented above.)

Target condition: [Condition and objective indicators tracked]

Response to treatment: Baseline ([date]): [metrics]; Current ([date]): [metrics]; Interval change: [quantitative change over specified period]

Concurrent standard care: [Relevant therapies and consultations for this indication]

Assessment & Plan

HBOT: [Tolerance summary]; [Protocol deviations and rationale if any]. Plan: [Continue daily M–F / Hold / Discontinue]; Next session: [date or schedule]; Modifications: [None planned / Specify]

Wound care: [Dressing and offloading plan]; [Pending consultations—vascular, podiatry, ID]; Next formal measurement or 30-day reassessment: [date] (Include for wound indications.)

Safety follow-up: [ENT referral if ear complications]; [Glucose management instructions]; [Return precautions]

Cross-References

• Chamber operator log: [date]
• Wound measurement record or wound clinic note: [date]
• Photographs: [location/date]
• Relevant labs or imaging: [date]
• Consultant notes: [date]