Musculoskeletal EMG Biofeedback Session Note (Muscle Re-Education/Spasm)

Date of Service: [date]
Patient: [full name]; [MRN or DOB]
Clinician: [name, credentials]
Visit Type: Treatment Session
Session Focus: [motor control objective and target muscle/region framed functionally]

Subjective

[Change since last visit: improved / stable / worsened, with brief context]. [Current symptoms with quantifier: pain rating, spasm frequency, stiffness, or functional tolerance]. [Relevant activity triggers]. [HEP adherence and response]. (Include a brief patient quote only if clinically meaningful. If unable to obtain subjective report, state reason.)

Objective

EMG Setup: [Target muscle(s) and side(s)]; [electrode placement using anatomical landmarks]; [patient position during testing/training]; [signal quality and any repositioning needed]. (Document actual placement—do not infer.)

Baseline & Outcomes: (Report only values obtained today. If any condition was not assessed, state reason.)

Muscle/Side	Condition	Baseline	Post-training/Best	Motor Quality Notes
[muscle, side]	[rest / task]	[value + units]	[value + units]	[substitutions, cueing, carryover]

Biofeedback Training: [Training goal: down-training / up-training / timing-coordination / synergy reduction]. [Task description linked to function]. [Feedback mode: visual / auditory / threshold / bandwidth]. [Dosage: sets/reps/holds or minutes]. [Key cues provided]. [Performance: accuracy, consistency, assistance level]. Time with device: [minutes].

Other Skilled Interventions: [Intervention type, body region, parameters, response]. Time without device: [minutes]. (Omit if none performed.)

Assessment

[Progress toward plan-of-care goals based on today's EMG and performance]. [What improved: resting activity, selective activation, timing]. [What persists: substitution patterns, limited endurance, inconsistent carryover]. [Patient tolerance and factors affecting performance]. [Rationale for continued skilled care]. (Base symptom statements on patient report, not EMG changes alone.)

Plan

Next Session: [Planned progression or task modification; feedback fading strategy; changes to muscle targets].

Home Program: [Exercises aligned with motor objective, dosage, key cues]. [Symptom guidance: acceptable soreness vs stop criteria]. (If unchanged: "HEP reviewed—no changes.")

Time & Codes

CPT Code	Description	Minutes	Units
[code]	[description]	[minutes]	[units]

(Document actual skilled minutes; exclude rest and non-skilled time. Do not round to 15-minute blocks.)

Timed Code Treatment Minutes: [total skilled timed minutes]
Total Treatment Time: [timed + untimed total]

Signature: [Clinician name, credentials, date/time]