Pelvic Floor Biofeedback Therapy Session Note (Fecal Incontinence)

Date of service: [Date of service]

Treating clinician: [Clinician name, credentials]

Location: [Clinic/site]

Session number: [Session X of Y]

Primary diagnosis: [Fecal incontinence diagnosis]

Timed-code treatment minutes: [Minutes]

Total treatment time: [Minutes]

Consent for internal sensors/rectal balloon: [obtained / declined / not applicable] (If internal work was planned but not performed, state reason.)

Subjective

[Interval history since last visit] (Begin with current priority concern. Cover: FI episode frequency and severity changes, urgency episodes, bowel diary summary if available, identified triggers, home program adherence with barriers, and functional impact. If diary not brought, note this and summarize verbal recall.)

Objective

• Diary-derived metrics: [FI episodes per interval, urgency frequency, stool form distribution, ability to defer urge] (Include only if diary or verbal recall provided.)
• Pelvic floor assessment: [Method: external observation / digital exam / surface EMG / intra-anal EMG / manometry] — [Resting tone, squeeze strength, endurance, coordination quality, compensatory patterns]
• Validated instruments: [Instrument name, score, date] (Include only if reassessed this session.)
• Rectal sensation/balloon training: [Indication, method, thresholds, patient response] (Include only if performed; otherwise omit entirely.)

Interventions and Response

• Biofeedback training: [FI mechanism addressed: weakness / coordination / urgency management / hyposensitivity] — [Modality/device] — [Exercise parameters: contraction type, hold/rest duration, reps/sets, progressions] — [Skilled cueing provided] — [Immediate response and tolerance]
• Bowel habit and lifestyle counseling: [Topics covered: stool consistency strategies / dietary modifications / toileting behaviors / skin care as relevant] — [Patient understanding via teach-back]
• Home exercise program: [Exercises prescribed or progressed with dose and frequency] — [Safety parameters] — [Patient demonstration of competence]
• Adverse events: [None / Description and actions taken]

Assessment

Progress toward goals: [Clinical synthesis of diary trends, device metrics, and functional reports with objective anchors]

Contributing factors: [Primary contributors: stool consistency / urgency management deficit / strength-endurance deficit / sensation deficit / behavioral triggers] — [Barriers to progress] — [Clinical hypothesis if applicable, explicitly labeled and tied to findings] — [Rationale for continued skilled care]

Plan

• Next session focus: [Specific objectives and what will change or progress]
• HEP: [Continue / modify] — [Specific exercises, doses, progression criteria]
• Reassessment: [Metrics or instruments to reassess and timing]
• Coordination: [Communication with referring provider, referrals if indicated] (Include referral if red flags: new bleeding, severe pain, weight loss, fever, neurologic changes.)
• Follow-up: [Visit frequency and planned decision points]