Pelvic Floor Biofeedback Therapy Session Note (Urinary Incontinence)

Patient: [name, DOB, MRN]
Date/Time: [date, start time – end time]
Clinician: [name, credentials]
Visit: [number in episode]; Diagnosis: [UI type and relevant comorbidities]
Session Focus: [patient-centered focus for today]

Subjective

[Interval changes since last session] (State trajectory [improved / stable / worsened] with 1–2 quantitative anchors such as leakage episodes/day, pad usage, bother rating, or nocturia. Include relevant triggers and any intervening events like UTI, medication changes, or illness.)

[Incontinence type and severity] (Specify [stress / urgency / mixed (predominant: stress / urgency)] with measurable severity anchors.)

• Bladder diary review: [daytime voids, nocturia, leakage episodes, pad count with trend vs baseline/prior] (If unavailable: "Diary not available; verbal recall used.")
• HEP/bladder training adherence: [consistent / partial / minimal] — [barriers and facilitators]
• Validated outcome measure: [instrument name, date, score] (Only if administered this session.)

Objective

• Biofeedback setup: [sEMG / pressure / sEMG + pressure] for [up-training / down-training / coordination / urge suppression]; [sensor type and placement]; [patient position] (Include consent/chaperone documentation per policy when internal sensors used.)
• Baseline metrics: [resting pelvic floor activity]; [return-to-baseline ability]
• Performance metrics: [contraction isolation/quality]; [peak/average values]; [hold time achieved]; [repetitions]; [fatigue pattern]; [overflow/substitution: yes/no]
• Functional drills: [knack/pre-contraction success rate]; [urge suppression performance] (Include only if performed.)
• Interventions:
  • PME training: [position(s)], [sets x reps], [hold/rest seconds], [cueing], [progressions/regressions]
  • Relaxation/down-training: [techniques and parameters] (If performed.)
  • Behavioral strategies: [timed voiding interval, urge suppression steps, fluid timing] (Document teach-back accuracy.)
  • Education: [topics covered and patient understanding]
• Tolerance/adverse events: [none / describe]

Assessment

[Progress toward goals] (If mixed UI, organize by subtype: Stress UI [improved / stable / worsened]; Urgency UI [improved / stable / worsened].)

[Response to today's session] (Tolerance, performance quality, notable biofeedback changes.)

Skilled intervention rationale: [explicit justification of clinician skill required] (e.g., adjusted sensor placement for optimal signal, provided graded motor-control cueing, progressed parameters based on observed fatigue, integrated functional pre-contraction with visual feedback.)

[Barriers and need for plan modification or escalation/referral] (Include only if applicable.)

Plan

• Next-visit focus: [specific intervention focus and metrics to target]
• HEP – PME: [sets x reps], [hold/rest seconds], [frequency/day], [positions]
• HEP – Bladder training: [target voiding interval], [urge response strategy] (Include only if applicable.)
• Fluid/dietary goals: [intake target, timing, irritant modification] (Include only if applicable.)
• Instructions provided: [written / digital / verbal]; teach-back [demonstrated / not demonstrated]
• Coordination: [communication to referring clinician or need for medical evaluation] (Include only if applicable.)

Time & Signature

Timed Minutes: [skilled direct contact time]
Total Treatment Time: [timed + untimed billable time]
Signature: [clinician name, credentials, date/time]