Pelvic Floor Biofeedback Therapy Session Note (Dyssynergic Defecation/Constipation)

Date/Time: [Date of service; start and stop times if applicable]

Patient: [Patient name; DOB]

Clinician: [Clinician name; credentials]

Session: [Session number in protocol, e.g., "Session 3 of planned 6"]

Indication: [Working diagnosis]

Consent: [Consent for anorectal instrumentation obtained; chaperone offered/present per policy]

Subjective

[Interval history since last session]

• Bowel diary status: [completed / not completed] (If not completed, state: "diary not completed; subjective recall used.")
• BM frequency: [Average bowel movements per week]
• Stool form: [Typical Bristol stool type]
• Straining severity: [none / mild / moderate / severe]
• Incomplete evacuation: [present / absent]
• Time on toilet: [Average minutes per attempt]
• Digital maneuvers: [used / not used] (If used, briefly describe.)
• Laxatives/suppositories: [yes / no] (If yes, list type and frequency.)
• Symptoms impacting training: [Pain, bloating, or other relevant symptoms; state "none" if absent]
• Home practice adherence: [Days per week performed; duration per session; barriers encountered]

Objective

• Session setup: [Device type: manometry-guided / EMG-guided / combined]; [Balloon use: yes / no; volume if used]; [Patient position: commode-seated / left lateral / supine / other]
• Baseline recto-anal function: [Resting tone, rectal propulsion, and anal relaxation pattern observed at session start]

Recto-anal coordination training (Include only if performed this session.)

• Coaching targets: [Targets addressed, e.g., exhale-based bearing down, pelvic floor relaxation, abdominal pressurization, posture]
• Push maneuvers: [Number of attempts completed]
• Cueing level required: [independent / minimal / moderate / maximal]
• Quantitative metrics: [Rectal propulsion; anal relaxation pattern; coordination quality] (Include if measured.)

Balloon expulsion practice (Include only if performed this session.)

• Balloon volume/position: [Volume in mL; position confirmation]
• Trials: [Number of attempts]
• Assistance provided: [none / coaching cues / gentle traction]
• Outcome: [Expulsion achieved: yes / no; time to expel if successful]

Sensory retraining (Include only if performed this session.)

• Indication: [Reason for sensory work, e.g., rectal hyposensitivity]
• Volumes used: [Range of inflation volumes in mL]
• Thresholds tracked: [First sensation; desire/urge; maximum tolerable]

Assessment

[Interpretation of progress toward recto-anal coordination goals] (Reference objective training metrics and bowel diary trends. Identify barriers such as pain, stool consistency, technique, positioning, or adherence.)

[Patient tolerance and adverse events] (Explicitly state "no adverse events" if none; otherwise describe.)

[Clinical reasoning for continued skilled therapy]

Plan

• Next session: [Timing and primary focus for next visit]
• Home program: [Breathing and simulated defecation practice frequency and duration; positioning and posture cues; relaxation techniques as applicable]
• Diary tracking: [Elements patient should monitor before next session]
• Discharge readiness criteria: [Coordinated pattern with minimal cueing; improved diary metrics; normalized balloon expulsion if used as benchmark]
• Communication: [When to notify referring provider] (Include if indicated.)

(Each session note should reflect interventions performed today. Omit sections for non-performed interventions. If specific information is unavailable, state this explicitly.)